What is VISALIA POST ACUTE's CMS rating?

VISALIA POST ACUTE has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does VISALIA POST ACUTE have?

VISALIA POST ACUTE has 74 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at VISALIA POST ACUTE?

VISALIA POST ACUTE has a three-star staffing rating from CMS with 0.21 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is VISALIA POST ACUTE located?

VISALIA POST ACUTE is located in VISALIA, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does VISALIA POST ACUTE have?

VISALIA POST ACUTE has 176 certified beds.

Who owns VISALIA POST ACUTE?

VISALIA POST ACUTE is a for profit - limited liability company facility and is part of the PACS GROUP chain.

Is VISALIA POST ACUTE safe?

VISALIA POST ACUTE has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at VISALIA POST ACUTE stick around?

VISALIA POST ACUTE has average staff turnover at 39%, which is typical for the nursing home industry.

Was VISALIA POST ACUTE ever fined?

No, VISALIA POST ACUTE has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is VISALIA POST ACUTE on any federal watch list?

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

What have inspectors found at VISALIA POST ACUTE?

Medicare inspectors have found 74 deficiencies at VISALIA POST ACUTE: 74 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting VISALIA POST ACUTE?

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

How does VISALIA POST ACUTE compare to other nursing homes?

VISALIA POST ACUTE has a 2-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

VISALIA POST ACUTE | 50/100 (Grade C)

Sept 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to assess, notify the physician and treat a change of condition for one of three sampled residents (Resident 1) when Resident 1'...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to assess, notify the physician and treat a change of condition for one of three sampled residents (Resident 1) when Resident 1's left foot 2nd toe was swollen, had drainage coming from it and dry crusty debris covering the top of the toe and the nail bed. These failures resulted in a delay of care and the potential for Resident 1's foot to worsen. Findings:During a concurrent observation and interview on 8/14/25 at 10:49 a.m. with Resident 1 in Resident 1's room, Resident 1 was lying on bed with her feet exposed. Resident 1's left foot appeared swollen, there were debris between the toes, a circular dried scab/skin on the inside of the foot, and the second toenail bed and top of the toe was covered with a lumpy and bumpy debris (cauliflower in appearance) that was dry, yellow, and crusty in appearance.During a review of Resident 1's Shower/Bed Bath Sheet (SBBS) dated 8/7/25 (7 days prior to the observation), the SBBS indicated, CNA: identify any skin issues.healing scab on left foot (top).Licensed Nurse: Review information and take follow-up action as indicated.Is this a new skin issue or change.Yes.No.(there was no documented response by the licensed nurse) .Follow-up action: (no documented response by licensed nurse) .(signed by LVN 2).During a concurrent observation and interview on 8/14/25 at 11:20 a.m. with Licensed Vocational Nurse (LVN) 1 and Resident 1, in Resident 1's room, LVN 1 donned gloves and began evaluating Resident 1's left foot. LVN 1 stated Resident 1's 2nd toe was swollen, dry, had drainage coming from it and looked infected. LVN 1 began cleaning and removing the debris from Resident 1's left toes. While cleaning the debris from the toes the base of the wound opened at the bottom of the 2nd and 3rd toes and LVN 1 was able to remove the debris that were covering the nail bed and top of the 2nd toe. When the debris were removed from the 2nd toe, the nail bed area was white and soft. The 2nd toe had no nail. LVN 1 stated there were no current treatments being administered to the left foot.During an interview on 8/14/25 at 11:53 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had a history of injuring her left foot during a transfer. CNA 1 stated initially the injury was red and the skin was torn back. CNA 1 stated the 2nd toe had looked like a cauliflower since the initial injury. During a concurrent interview and record review, on 9/3/25 at 12:14 p.m. with LVN 2, LVN 2 stated when there was a skin issue identified on a SBBS and there was no ongoing treatment to the area a change of condition should have been done. LVN 2 stated there was no change of condition done on 8/7/25 when the healing scab on the left foot was identified because there was ongoing treatment to the area. LVN 2 reviewed the clinical record and was unable to provide evidence of any ongoing treatment or monitoring to the left foot on 8/7/25.During an interview on 9/3/25 at 10:44 a.m. with Director of Nursing (DON), DON stated when staff were aware of Resident 1's left foot skin issues there should have been a change of condition completed, the physician should have been notified, and any new orders should have been implemented.During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2/2021, the P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition.need to alter the resident's medical treatment significantly.A significant change of condition is a major decline or improvement in the resident's status that.will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to reevaluate wounds when the treatment orders were ending for one of three sampled residents (Resident 1). This failure had the potential to ...

Read full inspector narrative →

Based on interview and record review, the facility failed to reevaluate wounds when the treatment orders were ending for one of three sampled residents (Resident 1). This failure had the potential to result in worsening of Resident 1's wounds and going untreated.Findings:During a review of Resident 1's Progress Notes (PN) dated 6/25/25 at 4 p.m. the PN indicated, Resident is sitting up in w/c (wheelchair) just arrived from (hospital name) appointment.skin assessment done, noted to have dry blood on the left foot sock, removed sock to left foot 2nd toe left toe noted nail is not intact and 2nd toe is bleeding, left 2nd toe nail was smashed, and nail is off from nail bed, notify MD (doctor of medicine).cleanse with NS (normal saline), pat dry apply bacitracin (antibiotic ointment) very (sic) shift, leave open to air. Cleanse skin tr=ear (sic) to left lateral (side of the body part) foot, pat dry, apply bacitracin every shift, monitor for infection and worsening shift x14 days, follow up with wound Dr.During a review of Resident 1's Treatment Administration Record (TAR) dated 7/2025, the TAR indicated the last day of treatment and monitoring to the left foot 2nd toe and left lateral foot was 7/6/25 on day shift.During an interview on 8/14/25 at 1:14 p.m. with Treatment Nurse (TN) 1, TN 1 stated when the treatment order ended on 7/6/25, the wounds should have been reevaluated to see if treatment should continue or be discontinued. TN 1 stated there should be progress notes documented when the reevaluation was completed. TN 1 was unable to provide documentation of the wounds being re-evaluated. During a concurrent interview and record review, on 9/3/25 at 10:44 a.m. with Director of Nursing (DON), DON stated when treatment orders were ending the wounds being treated were to be reevaluated and a progress note was to be completed indicating whether the wound treatment needed to be continued or if the wound had resolved. DON was unable to provide documentation of the wound being reevaluated. Policy requested and none provided.

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 F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to follow physician orders when there was no referral to the wound care doctor and treatment was not provided to one of three sampled resident...

Read full inspector narrative →

Based on interview and record review, the facility failed to follow physician orders when there was no referral to the wound care doctor and treatment was not provided to one of three sampled residents (Resident 1) when it was ordered by the podiatrist. This failure resulted in Resident 1's wound going untreated and had the potential for Resident 1's wound to worsen. Findings:During a review of Resident 1's Podiatry Evaluation (PE) dated 6/2/25, the PE indicated, Wound of foot.The patient presently has a wound of the lower extremities. A dressing was applied today. Nursing was notified of the presence of the wound. Will defer wound management to the wound care MD (Doctor of Medicine). If recommendations for wound care are requested from a podiatry standpoint please reconsult specifically for that reason.wound x1 noted to left dorsal (back part of the body part) forefoot measuring 3x3 cm (centimeters-a unit of measurement).During a concurrent interview and record review, on 9/3/25 at 11:11 a.m. with Treatment Nurse (TN) 1, Resident 1's clinical record was reviewed. TN 1 was unable to provide documentation of Resident 1 being referred to the wound doctor. TN 1 stated when the nurse was made aware of the wound, the nurse should have completed a change of condition and notified the MD. TN 1 stated Resident 1 should have been referred to the wound doctor when the podiatrist ordered it.During a concurrent interview and record review, on 9/3/25 at 10:44 a.m. with Director of Nursing (DON), Resident 1's clinical record was reviewed. DON stated he was unable to provide evidence of Resident 1 being referred to the wound doctor as ordered by the podiatrist. During a review of the facility's policy and procedure (P&P) titled, Foot Care dated 10/22, the P&P indicated, Residents are provided with foot care and treatment in accordance with professional standards of practice.Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions.

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a change of condition for one of three sampled residents (Resident 1) when Resident 1's ...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure the physician was notified of a change of condition for one of three sampled residents (Resident 1) when Resident 1's wound worsened. This failure had the potential for Resident 1 to experience a delay in care. Findings: During a review of Resident 1's Care Plan (CP) dated 2/19/25, the CP indicated, (Resident 1) is at risk for skin breakdown related.skin tears.Interventions.Check skin during daily care provisions. Notify physician of abnormal findings. During an observation on 5/29/25 at 11:25 AM in the hallway, Resident 1 had steri-strips (small adhesive strips used to close small wounds) to her right arm near the elbow. There was green drainage (often indicating infection) noted to the wound that could be seen on the steri-strips. During a concurrent interview and record review, on 5/29/25 at 1:10 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when she was checking Resident 1's right arm on 5/28/25 (one day prior) she noticed there was a green drainage coming from Resident 1's wound. LVN 1 stated she cleaned the wound and applied triple antibiotic ointment to the wound and left it uncovered on 5/28/25 and 5/29/25. LVN 1 was unable to provide evidence the physician was notified of the change of condition. LVN 1 stated the physician should have been notified when there was a change in the wound. During an interview on 5/29/25 at 1:38 p.m. with Assistant Director of Nursing (ADON), ADON stated when Resident 1's right arm wound was noted with green drainage the physician should have been notified. During a review of the facility policy and procedure (P&P) titled Change in a Resident's Condition or Status dated 2/2021, the P&P indicated, The nurse will notify the resident's attending physician or physician on call when there has been a(an).need to alter the resident's medical treatment significantly.The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

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 F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1) physician's orders were followed. This failure resulted in Resident 1 not receiving a do...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 1) physician's orders were followed. This failure resulted in Resident 1 not receiving a dose of intravenous (IV - used to administer medications directly into the vein) antibiotics (used to treat infection) and the potential for Resident 1's urinary tract infection to worsen. Findings: During a review of Resident 1's Physician's Orders (PO), the PO indicated, Ceftriaxone (antibiotic).use 1 gram (unit of measurement) intravenously one time a day for urinary tract infection for 7 days.start date 5/8/25. During a review of Resident 1's Care Plan (CP) dated 5/7/25, the CP indicated, Infection: Resident is at risk for complications related to Urinary Tract Infection and dehydration ceftriaxone.Interventions.Medication per physician's order. During a concurrent interview and record review on 5/15/25 at 3:13 p.m. with Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record (MAR) dated 5/25 was reviewed. The MAR indicated Ceftriaxone was not administered on 5/12/25. ADON was unable to provide evidence the medication was administered and stated when the medication was administered it should have been documented on the MAR. During a review of the facility's policy and procedure (P&P) titled, IV (intravenous) Administration undated, the P&P indicated, Documentation.Document in the patient's medical record.Medication, amount, and type of diluent.date, time of administration.route.administering clinician's initials.

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

Safe Transfer (Tag F0626)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based an interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to the...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based an interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to the facility after hospitalization. This resulted in Resident 1 having unnecessary stay in the hospital and violated Resident 1's rights. Findings: During an interview on 3/19/25 at 3:12 p.m. with acute hospital Social Worker (SW), SW stated on 3/19/25 she notified facility to inquire whether they would be permitting Resident 1 to return to the facility. SW stated she was made aware facility was not permitting Resident 1 to return to the facility. During an interview on 3/19/25 at 4:22 p.m. with Resident 1, Resident 1 stated on 3/13/25 she was not able to hold any food down and had severe abdominal pain and requested to be sent to the acute hospital. Resident 1 stated she feels better and would like to return to the facility. Resident 1 stated, I'm comfortable there [facility]. I want to go back, I've made friends there. During a review of Resident 1's admission Record (AR), dated 3/20/25, the AR indicated Resident 1 was a female initially admitted to the facility on [DATE]. Resident 1's quarterly Minimum Data Set (MDS-a federally mandated resident assessment tool) dated 1/23/25, indicated Resident 1 had a BIMS (Brief Interview for Metal Status-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 14 (13 to 15 cognition is intact). The Progress Notes dated 3/13/25 at 1:20 p.m. indicated Resident 1 had complain of severe abdominal pain and requested to be sent out to the acute hospital. During an interview an interview on 3/20/25 at 12:09 p.m. with Administrator and Assistant Director of Nurses (ADON), ADON stated Resident 1 was transferred to the acute hospital for abdominal pain. Administrator stated on 3/19/25, hospital SW were made aware facility had no beds available and would not be permitting Resident 1 to return to the facility even when a bed became available. Administrator stated, We are not taking her [Resident 1] back. During a review of the facility's policy and procedure (P&P) titled, readmission to the Facility, dated 3/2017, the P&P indicated, Residents who have been discharged to the hospital or for therapeutic leave will be given priority readmission to the facility.

Feb 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 F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure adult protective services (APS) was notified for one of three sampled residents (Resident 1) when Resident 1 was discharged from the...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure adult protective services (APS) was notified for one of three sampled residents (Resident 1) when Resident 1 was discharged from the facility home alone, when staff had concerns for her safety due to Resident 1's cognitive status. This failure had the potential to result in Resident 1 having unmet care needs and being put at risk for harm. Findings: During a review of Resident 1's Discharge Summary (DS), dated 1/17/25 at 12:05 p.m., the DS indicated, discharge date .1/23/25.Discharge location.home.Activity status.moderate assist (assistance) (50% of the effort being performed by staff) .Bed mobility.moderate assist.Transfer.substantial/maximum assist (75% of the effort being performed by staff).Dressing.moderate assist.Bathing.moderate assist.grooming and hygiene.moderate assist.toilet use.moderate assist.Incontinent-Bladder.yes.Incontinent-Bowel.yes. During a review of Resident 1's Care Plan (CP), dated 12/2/24, the CP indicated, Cognitive impairment: Resident exhibits cognitive loss.Interventions/Task.Anticipate needs and meet promptly.Provide memory cues as appropriate. During a review of Resident 1's Progress Notes (PN), dated 1/23/25 at 5:26 p.m., the PN indicated, Resident is discharged for home.via Uber by herself.Per MD (doctor of medicine) cycle medications can be brought home but were left by resident as [sic] discharge was not certain 5 minutes before resident's ride arrived.Writer called resident to inform her of medications left behind but resident was not responding. During an interview on 2/3/25 at 1:44 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 1/23/25 she discharged Resident 1 home via Uber. LVN 1 stated Resident 1 was confused on the day of discharge and LVN 1 was attempting to get ahold of Resident 1's contacts but she was only able to leave messages. LVN 1 stated she delayed Resident 1's discharge as much as she could because it was scary to let Resident 1 discharge without anyone knowing. During an interview on 2/3/25 at 1:54 p.m. with ADON, ADON stated during Resident 1's stay at the facility Resident 1 would experience episodes of confusion and was sent to the hospital because of the confusion. During an interview on 2/3/25 at 2:06 p.m. with Social Service Director (SSD), SSD stated when there were safety concerns with Resident 1's discharge, the discharge should have been reported to APS. Facility policy was requested but none was provided.

Feb 2025 18 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

Based on observation, interview, and record review, the facility failed to ensure a functioning wall light was provided in a resident's room for one of six sampled residents (Resident 139). This failu...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure a functioning wall light was provided in a resident's room for one of six sampled residents (Resident 139). This failure had the potential to compromise the safety of the resident. Findings: During an observation on 1/27/25 at 11:07 a.m. in Resident 139's room, there was a light on the wall above Resident 139's bed that did not turn on and the string to turn on the light was detached. During an interview on 1/27/25 at 11:09 a.m. with Director of Staff Development (DSD), DSD stated she just found out right now that the string to pull to turn on the light was detached and the light was broken. DSD stated she does not know how long it had been out of service. During an interview on 1/27/25 at 11:13 a.m. with Maintenance Supervisor (MS), MS stated he was not aware Resident 139's light was broken. MS stated the light should be working for Resident 139's use. During a record review of the facility's DEPARTMENTAL MAINTENANCE WORKSHEET (DMW),'' dated 1/25/25, the DMW indicated, LOCATION OF DEFICIENCY BE SPECIFIC: 3C DESCRIPTION OF DEFICIENCY BE SPECIFIC: light Chord broke .DATE CORRECTED: 1/25/25. During a review of the facility's policy and procedure (P&P) titled, Maintenance Service, dated December 2009, the P&P indicated, 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .2f. establishing priorities in providing repair service.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to provide written information on bed-hold (holding a resident's bed during hospitalization) for two of two sampled residents (Resident 51 and...

Read full inspector narrative →

Based on interview and record review, the facility failed to provide written information on bed-hold (holding a resident's bed during hospitalization) for two of two sampled residents (Resident 51 and Resident 68). This failure had the potential to create uncertainty for Resident 51 and Resident 68 to return to the facility and return to their previous rooms. Findings: During a concurrent interview and record review on 1/30/25 at 10:53 a.m. with Admissions Director (AD), AD stated in the facility's admission packet there was a form that discussed bed-hold upon admission. AD stated before the resident was sent out, the nurse should inform the resident and/or resident representative about a bed-hold. AD stated if the resident and/or resident representative decided to take the bed-hold, the doctor would order a seven-day bed-hold for the resident to be able to return to the facility. During a concurrent interview and record review on 1/30/25 at 10:59 a.m. with Assistant Director of Nursing (ADON), Resident 51's medical record (MR) was reviewed. The MR indicated Resident 51 was transferred and admitted to acute care hospital on 6/24/24. ADON was unable to provide evidence that nurses provided written information about bed-hold. During a concurrent interview and record review on 1/30/25 at 11:10 a.m. with ADON, Resident 68's MR was reviewed. The MR indicated Resident 68 was transferred to the acute care hospital on 1/25/25 for evaluation and treatment of laceration (cut) to the scalp after a fall. ADON was unable to provide evidence that nurses provided information about bed-hold. During a review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, [undated], the P&P indicated, All Residents and/or representatives are provided written information regarding the facility and state (if applicable) bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer (sic) source, are provided written notice about these polices at least twice: a. notice 1: well in advance of any transfer (e.g., in the admission packet and notice 2: at the time of transfer (or, if transfer was an emergency, within 24 hours).

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) Resident Matrix (MDSRM), was accurate and up to date for two...

Read full inspector narrative →

Based on interview and record review the facility failed to ensure the Minimum Data Set (MDS-a federally mandated resident assessment tool) Resident Matrix (MDSRM), was accurate and up to date for two of six sampled residents (Resident 135, and Resident 152). This failure had the potential for Resident 135 to have unmet care needs and inaccurate medical records for both Resident 135, and Resident 152. Findings: 1. During a review of Resident 135's, MDSRM, dated 1/27/25, the MDSRM indicated, Resident 135 was on Transmission based precaution (TBP-set of infection control measures). During an interview on 1/27/25 at 11:32 a.m. with Licensed Vocational Nurse, (LVN) 5, LVN 5 stated Resident 135 does not use oxygen or have a breathing type of device. During an interview on 1/28/25 at 5:05 p.m. with Minimum Data Set Coordinator (MDSC), MDSC stated that is a coding error because Resident 135 is not on TBP. During a concurrent interview and record review on 1/29/25 at 9:53 a.m. with Director of Nursing (DON), Resident 135's, MDS Sections J and O, dated 11/18/24 was reviewed. The Section J indicated, other health conditions, a, shortness of breath or trouble breathing with exacerbation (e.g walking, bathing, transferring) indicated, no. Shortness of breath or trouble breathing when sitting at rest, indicated, no. Z. None of the above indicated, yes. Section O, special treatments, procedures and programs indicated, Respiratory Therapy 0. During a interview on 1/29/25 at 11:19 a.m. with LVN 5, LVN 5, stated Resident 135 has not been on TBP for a long time. LVN 5 stated the last time was in October 2024. 2. During an observation on 1/27/25 at 11:18 a.m. in Resident 152's room, Resident 152 did not have a tracheostomy (medical device to maintain airway for breathing) or dressing to Resident 152's neck or airway. During a review of Resident 152's admission Record (AR), dated 1/29/25, the AR indicated Resident 152's admission date was 11/21/24. During a review of Resident 152's Physician's Order (PO), dated 12/17/24, the PO indicated, Tracheostomy care: Cleanse stoma with NS [Normal Saline-sterile salt water], pat dry, cover with 2x [by] 2 dry dressing .discontinued on 12/17/24. During a concurrent interview and record review on 1/28/25 at 4:45 p.m. with Minimum Data Set Coordinator (MDSC), the facility's MDS Resident Matrix (MDSRM), dated 1/27/25 was reviewed. The MDSRM indicated, on 1/27/25, tracheostomy was check marked for Resident 152's matrix. MDSC stated, I update the matrix twice a week on Mondays and Fridays. MDSC stated the tracheostomy care has been discontinued since 12/17/24. MDSC stated she did not update the matrix for Resident 152 and tracheostomy should not have been marked on the matrix. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation,'' dated July 2017, the P&P indicated, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Baseline Care Plan (BCP - an initial person-centered care p...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide Baseline Care Plan (BCP - an initial person-centered care plan within the first 48 hours of admission that provide instructions for care of the resident) Summary for three of three newly admitted sampled residents (Resident 311, Resident 312, and Resident 313). This failure had the potential for Resident 311, Resident 312, and Resident 313 to not receive the care and the safeguards necessary within the first 48-hours of admission. Findings: During a concurrent interview and record review on 1/29/25 at 10:28 a.m. with Assistant Director of Nursing (ADON), Resident 311's admission Record (AR) was reviewed. The AR indicated Resident 311 was admitted on [DATE]. During a concurrent interview and record review on 1/29/25 at 10:30 a.m. with ADON, Resident 311's BCP summary, dated 1/13/25, was reviewed. The BCP summary indicated, The resident and/or the resident representative participated in the baseline care plan review with a printed/written summary provided. The BCP summary section Printed Baseline Care Plan Provided via was blank and there was no signature of the resident and/or the resident representative to signify receipt of the BCP summary. ADON was unable to provide documented evidence of the BCP being provided to the resident and/or the resident representative. During a concurrent observation and interview on 1/27/25 at 11:12 a.m. in Resident 312's room with Resident 312, Resident 312 was awake and oriented. Resident 312 stated she did not receive a BCP summary on admission. During a concurrent interview and record review on 1/27/25 at 11:21 a.m. with ADON, Resident 312's AR was reviewed. The AR indicated Resident 312 was admitted on [DATE]. During a concurrent interview and record review on 1/27/25 at 11:25 a.m. with ADON, Resident 312's BCP summary, dated 1/25/25, was reviewed. The BCP summary indicated, Resident and/or Resident Representative participated in the BCP review with a printed/written summary provided. The BCP section Printed Baseline Care Plan Summary provided via was blank and there was no signature of the resident and/or the resident representative to signify receipt of the BCP summary. ADON was unable to provide documented evidence of the BCP being provided to the resident and/or the resident representative. During a concurrent interview and record review on 1/31/25 at 9:25 a.m. with ADON, Resident 313's AR was reviewed. The AR indicated Resident 313 was admitted on [DATE]. During a concurrent interview and record review on 1/31/25 at 9:26 a.m. with ADON, Resident 313's BCP summary, dated 1/13/25, was reviewed. The BCP summary indicated, The resident and/or the resident representative participated in the baseline care plan review with a printed/written summary provided. The BCP summary section Printed Baseline Care Plan Provided via was blank and there was no signature of the resident and/or the resident representative to signify receipt of the BCP summary. ADON was unable to provide documented evidence of the BCP being provided to the resident and/or the resident representative. During a review of the facility's policy and procedure (P&P) titled, Baseline Care Plan, dated 3/2022, the P&P indicated, 4. The resident and/or the resident representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) .5. Provision of the summary to the resident and/or resident representative is documented in the medical records.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure the Medical Doctor (MD) reviewed and countersigned a verbal order (VO) for two of two sampled residents (Resident 101 and Resident 1...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure the Medical Doctor (MD) reviewed and countersigned a verbal order (VO) for two of two sampled residents (Resident 101 and Resident 127). This failure had the potential for the nurse to not properly follow the VO for Resident 101 and Resident 127. Findings: 1. During a concurrent interview and record review on 1/29/25 at 4:15 p.m. with Licensed Vocational Nurse (LVN) 9, Resident 127's Nurse's Note (NN), dated 12/19/24 was reviewed. Resident 127's NN indicated, upon assessment Resident 127 had crackles (indicates fluid in small airways) in the right lung, diminished (no sound or dull sound) breath sounds heard in the left lung with difficulty breathing. Resident 127 was on oxygen at 3 Liters. MD ordered Resident 127 sent out to the hospital. LVN 9 stated she notified the MD of Resident 127's condition. LVN 9 stated MD gave a verbal phone order to send resident out to hospital. During a concurrent interview and record review on 1/29/25 at 4:20 p.m. with LVN 9, Resident 127's Medical Record (MR) was reviewed. LVN 9 stated, I can't find the signed verbal doctors order in the resident's chart. LVN 9 stated the signed VO should be in the resident's chart. 2. During a concurrent interview and record review on 1/30/25 at 12:11 p.m. with Minimum Data Set Coordinator (MDSC), Resident 101's Medical Record (MR) was reviewed. MDSC stated the MD should have given a VO for Resident 101 to be sent out to the hospital. MDSC stated she could not find the signed VO in Resident 101's chart and stated the VO should have been put in the chart. During a review of the facility's policy and procedure (P&P) titled, Verbal Orders, dated 2001, the P&P indicated, The practitioner will review and countersign verbal orders during his or her next visit.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Activities of Daily Living (ADL) for one of seven sampled residents (Resident ...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Activities of Daily Living (ADL) for one of seven sampled residents (Resident 81) when nursing staff did not provide personal grooming and hygiene. This failure had the potential to result in Resident 81's lowered self-esteem and the potential make Resident 81 susceptible to disease and/or infection. Findings: During an observation on 1/28/25 at 9:46 a.m. in Resident 81's room, Resident 81 sat on his bed, still wearing a hospital gown. Resident 81's hair was long and had not been combed. Resident 81's facial hair, moustache and beard were long. Resident 81's fingernails were long and had blackish substance inside the tips of all the fingernails. Resident 81 stated, I needed to be shaved. My fingernails also needed to be trimmed. I am waiting for the Certified Nursing Assistant (CNA) to trim my nails. During an interview on 1/28/25 at 10 a.m. with Registered Nurse (RN) 1 in Resident 81's room, RN 1 stated [Resident 81] had not been showered. RN 1 stated Resident 81 had not been combed and had not been changed. RN stated Resident 81 needed to be shaved and fingernails trimmed. RN 1 stated, Resident 81's fingernails were dirty. During an interview on 1/29/25 at 11:04 a.m. with CNA 2, CNA 2 stated, [Resident 81] frequently scratches his legs, private area, and his fingers get dirty. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, dated 03/2018, the P&P indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL).

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

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 84) in Hospice Care (end of life care) received care and treatment for the edema...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 84) in Hospice Care (end of life care) received care and treatment for the edema (swelling) on both the legs when: 1. Weekly Nursing Assessments did not indicate Resident 84 had edema. 2. After Hospice Nurse (HPN) notified Medical Doctor (MD), MD did not provide treatment orders for Resident 84's edema. These failures resulted in Resident 84's not receiving the necessary services, treatment and quality of care needed for the swelling in both her legs. Findings: During a concurrent observation and interview on 1/28/25 at 8:44 a.m. with Hospice Nurse (HPN) and Registered Nurse (RN) 1, in Resident 84's room, Resident 84 was sitting up in bed. Both of Resident 84's legs had pitting (when pressure is applied to the swollen area, an indentation [pit] remains) edema. HPN stated Resident 84 was dependent, and unable to do things for herself. HPN stated Resident 84's legs were edematous. RN 1 stated Resident 84 was not receiving any medications for her edema. During a concurrent interview and record review on 1/30/25 at 11:22 a.m. with Assistant Director of Nursing (ADON), Resident 84's Nursing Progress Notes (NPN), dated 12/20/24, was reviewed. The NPN indicated, Certified Nursing Assistant [CNA] notified the charge nurse the resident had a seizure. Charge nurse assessed the resident and found resident had pitting edema to lower extremities. Charge nurse notified HPN. HPN notified MD (medical doctor). During a concurrent interview and record review on 1/30/25 at 11:30 a.m. with ADON, Resident 84's Weekly Nursing Assessment (WNA), dated 1/13/25, 1/20/25, and 1/27/25 were reviewed. The WNA dated 1/13/25, 1/20/25, and 1/27/25 did not indicate the presence of edema to Resident 84's legs. 2. During a concurrent interview and record review on 11/30/25 at 11:32 a.m. with ADON, Resident 84's, Physician's Progress Notes (PPN), was reviewed. ADON was unable to find documentation of Resident 84's attending physician addressing Resident 84's pitting edema since he was notified on 12/20/24. During a concurrent interview and record review on 2/3/25 at 3:39 p.m. with Nursing Consultant (NC), Resident 84's PPN was reviewed. NC was unable to find physician documentation addressing the pitting edema. NC stated any change in condition the charge nurse needs to notify Hospice, Hospice will then contact the physician and obtain orders. During a review of the facility's policy and procedure (P&P) titled, Hospice Program, dated July 2017 the P&P indicated, In general, it is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs .12.The facility has designated (name of Hospice Care) to coordinate care provided to the resident by our facility staff and the hospice staff (Note. This individual is a member of the IDT with clinical and assessment skills .). He or she is responsible for b. Communicating with hospice representatives and other healthcare providers, participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the resident and family. During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 2/2021, the P&P indicated, 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. During a review of the facility's P&P, titled, Charting and Documentation, dated 7/2017, the P&P indicated, All services provided to the resident progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure sufficient communication between the facility'...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure sufficient communication between the facility's Registered Dietitian (RD) 1 and RD 2 employed by the dialysis center related to provision of lunch meal in a safe manner for one of one sample resident (Resident 139) who received dialysis three times a week. This failure had the potential to result in Resident 139's lunch to contain Time Temperature Control for Safety (TCS - food that requires time-temperature control to prevent the growth of bacteria) foods to include a turkey or tuna sandwich had inadequate monitoring of time/temperature control for food safety which placed Resident 139 at an increased risk for a foodborne illness. Findings: During a review of Resident 139's Resident Information, dated 2/3/25, Resident 139 was admitted to the facility on [DATE] with a diagnosis Dependent on Renal Dialysis. During an interview on 1/27/25 at 12:09 p.m. with Licensed Vocational Nurse (LVN) 10, LVN 10 stated Resident 139 left the facility early in the morning around 9 a.m. to go to the dialysis center and was expected to return between 3 to 4 p.m. LVN 10 stated Resident 139 told her he had his brown bag lunch sack already packed with his personal belongings he brought with him to the dialysis center. LVN 10 stated he usually does not like to eat it at the dialysis center and so he eats it when he returns to the facility. LVN 10 stated he goes to dialysis three times a week. During an interview on 01/28/25 at 1:10 p.m. with Resident 139 with Certified Nursing Assistant (CNA) 3, CNA 3 translated in Spanish, Resident 139 stated he would eat either two egg sandwhiches or two tuna sandwiches, cookies and crackers at 2:00 p.m. while at the dialysis center. During a record review of Resident 139's Minimum Data Set (MDS-assessment tool used to identify resident cognitive and physical function), Assessment Reference Date of 11/13/24, the MDS assessment indicated, Resident 139's Brief Interview for Mental Status (BIMS-assessment used to identify a resident's current cognition) score was 12 out of 15, which indicated Resident 139 had moderate cognitive impairment (significant difficulty with memory, attention, and problem solving). During an interview on 01/28/25 at 03:54 p.m. with Certified Dietary Manager (CDM), CDM stated Resident 139 received a turkey sandwich cut in half without cheese three times a week in his paper bag sack lunch, per Resident 139's request, to take with him to dialysis. CDM stated Resident 139's paper bag sack lunch also contained apple sauce, a fresh apple, two small package of graham crackers and a small package of LornaDoone cookies, and we hold fluids specifically for dialysis, so no fluid. CDM was asked if Resident 139 received egg salad sandwiches because resident reported he had that on Monday in his bagged sack lunch for dialysis, and CDM said no. CDM stated Resident 139 either received a turkey or tuna sandwich. During a concurrent interview and record review on 1/29/25 at 10:47 a.m. with RD 1, Resident 139's current physician orders and IDT (interdisplinary team) dialysis care plan dated 11/14/24 were reviewed. RD 1 stated she was responsible for coordinating nutrition care for Resident 139 with RD 2 who worked at the dialysis center. RD 1 stated Resident 139 goes to the dialysis center every Monday, Wednesday and Friday and chair time was at 10:30 a.m.-1:30 p.m. (the time he actually received his hemodialysis treatment; a treatment that removes waste products and excess fluid from the blood when the kidneys are no longer able to do so). RD 1 stated Resident 139 leaves the facility with a paper bagged sack lunch. During an interview on 1/29/25 at 10:55 a.m. with RD 1, RD 1 was not aware Resident 139 did not like to eat at the dialysis center and usually ate upon return to the facility, which was six to seven hours later, as reported by nursing. RD 1 stated that had never been reported to her and that was way too long to go with the food in the temperature danger zone. RD 1 stated she did not know if there was a refrigerator for resident's use to store food under temperature control for food safety, nor did she know the time in which Resident 139 would potentially eat his lunch at the dialysis center. During a review of the Food and Drug Administration Food Code Annex (FDAFCA), dated 2022, the FDAFCA indicated, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature Danger Zone 41º [degrees] F [Fahrenheit] to 135º F) too long.time/temperature control for safety foods held without cold holding temperature control for a period of 4 hours do not have any temperature control or monitoring. These foods can reach any temperature when held at ambient air temperatures as long as they are discarded or consumed within the four hours. During an interview on 1/29/25 at 11:12 a.m. with RD 1, RD 1 stated she spoke with nursing and was informed that nursing would give Resident 139 a fresh sandwich from stock provided by the kitchen stored in a designated food refrigerator for resident's located at the nursing station upon his return to the facility. RD 1 was asked what happened with his paper bagged sack lunch, and RD 1 stated she was unsure. During a telephone interview on 1/29/25 at 11:22 a.m. with RD 2 in the presence of RD 1, RD 2 stated resident's were not allowed to eat while in their chair receiving hemodialysis for infection control purposes. RD 2 stated they do not store resident's food at the dialysis center. RD 2 stated she had never seen him [Resident 139] with a paper bag sack lunch. RD 2 stated they do not look through their personal stuff, so he might eat in the lobby before or after dialysis but she would have no idea. During an interview on 1/29/25 at 4:20 p.m. with Resident 139 with RD 1 translating in Spanish, Resident 139 stated he had a peanut butter and jelly sandwich on Monday (1/27/24) in his paper bag sack lunch he had at the dialysis center but it was usually a tuna or turkey sandwhich, and he liked getting a fresh sandwich when he returned to the facility. Resident 139 stated he did sometimes eat his sandwhich provided to him in the paper bagged sack lunch in the lobby after his dialysis was done. During a review of Resident 139's IDT dialysis care plan (DCP) dated 11/14/2024, the DCP indicated, Resident requires hemodialysis related to End Stage Renal Failure.Dialysis Center: Mon [Monday], Wed[Wednesday] & Fri [Friday].Chair Time: 1030-1330 [10:30 a.m. - 1:30 p.m.].Pick up between 0845am-0915am [Resident 139 leaves the facility for dialysis center between 8:45 a.m. to 9:15 a.m.]. During a review of Resident 139's NURSING: HEMODIALYSIS COMMUNICATION OBSERVATION/ASSESSMENT; To be completed by Licensed Nurse prior to dialysis treatment form, dated 1/17/25 through 1/27/25, the communication form indicated a check mark next to Sack Meal. During a review of Resident 139's To be completed by the Dialysis Center following dialysis treatment. Return with resident to the facility post dialysis form, dated 1/17/25 through 1/27/25, it was noted that there was no field (requirement) located on the form to document whether Resident 139 arrived with a lunch, nor whether he consumed his lunch in the lobby at the dialysis center. During a review of Resident 139's To be completed by Licensed Nurse post dialysis treatment form, dated 1/17/25 through 1/27/25, it was noted that there was no field (requirement) located on the form to document whether Resident 139 returned with an uneaten paper bagged sack lunch, or not. During a review the facility's document titled, .Dialysis Communication: .Best Practice Workflow, dated 11/2024, the document indicated, Dialysis. The care of the resident receiving dialysis services must reflect ongoing communication, coordination and collaboration between the nursing home and the dialysis staff. Use of a Dialysis Communication Form helps ensure the coordination of safe and effective care of residents who need dialysis treatments. PRE [before]-Dialysis Communication: This is completed by the nurse before the resident leaves for a dialysis appointment. Documentation includes:Dialysis Access, Vital Signs, Dietary Information, General Conditions.Dialysis Center Communication: This is completed by the dialysis center after the dialysis treatment and is returned to the facility with the resident. Documentation includes: Dialysis Access,Vital Signs, Pre and Post Dialysis Weight, New Orders/Labs, Change of Condition during dialysis, Recommendations, POST [after]-Dialysis Communication: This is completed by the nurse after the dialysis treatment. Documentation includes: Dialysis Access, Vital Signs, General Conditions.

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to follow its policy and procedure (P&P) on Resident Rights, for one of six sampled residents (Resident 106) did not receive rout...

Read full inspector narrative →

Based on observation, interview, and record review the facility failed to follow its policy and procedure (P&P) on Resident Rights, for one of six sampled residents (Resident 106) did not receive routine dental services. This failure had the potential for poor eating and broken or lose teeth to go unnoticed. Findings: During an observation on 1/27/25 at 1:11 p.m. in Resident 106's room, Resident 106 did not have teeth. During a concurrent interview and record review on 1/30/25 at 3:35 p.m. with Social Services Assistant (SSA), Resident 106's Order Summary (OS), dated 6/1/24 was reviewed. The OS indicated, consult dental for oral hygiene with follow-up and treatment. SSA stated Resident 106's dental referral was missed. During a review of the facility's P&P titled, Resident Rights, dated 9/2009, the P&P indicated, e. choose[sic] a physician and treatment and participate in decisions and care planning.

CONCERN (D)

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

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to: 1. Provide the therapeutic diet as ordered for one of seven sampled residents (Resident 311) when: a. Resident 311 was serve...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to: 1. Provide the therapeutic diet as ordered for one of seven sampled residents (Resident 311) when: a. Resident 311 was served his nectar-thick (thickness of milkshake) drink and house nourishment after sitting out at room temperature for approximately five (5) hours on 1/27/25. b. Resident 311's meal tray did not have 8 fluid ounces (fl. oz) nectar-thick punch drink for lunch on 1/27/25. These failures had the potential for Resident 311 to not meet the nutritional requirements due to decreased palatability (tastiness). Findings: 1a. During an observation on 1/27/25 at 12:30 p.m. in Resident 311's room, Resident 311 was laying in bed. Two sippy cups, full of liquid, were on the nightstand, on the left side of Resident 311's bed. Neither sippy cup was within Resident 311's reach. Resident 311 was non-verbal (did not speak). Resident 311 had no teeth and constantly smacked his lips. Resident 311's left hand was contracted (unable to straighten due to shortening of tendons and muscles). During a concurrent observation and interview on 1/27/25 at 12:54 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 311's room. Two sippy cups were on Resident 311's nightstand, one sippy cup contained an orange-colored thickened liquid, and the other sippy cup contained a light, brown-colored thickened liquid. CNA 1 stated the two drinks had been placed in the room at around 8 a.m. today. CNA 1 stated those drinks were part of Resident 311's breakfast tray but the drinks must not have been given to the resident. CNA 1 stated Resident 311 could hold the sippy cup with his right hand. CNA 1 placed the sippy cup containing the orange-colored thickened liquid in Resident 311's right hand. Resident 311 was able to hold the sippy cup and bring it up to his mouth. Resident 311 started drinking quickly. CNA 1 stated Resident 311 was drinking so fast, Resident 311 must have been very thirsty. Resident 311 drank about 1/3 of the orange-colored thickened liquid. During an interview on 1/28/25 at 8:24 a.m. with Certified Dietary Manager (CDM), CDM stated the sippy cup with orange-colored thickened liquid was orange juice and the sippy cup with light brown thickened liquid was the house nourishment (milk based, liquid nutritional supplement). CDM was aware CNA gave Resident 311 the sippy cup with nectar thick orange juice at 12:54 p.m when it was on the nightstand since 8 a.m. CDM stated the temperature of the drink was out-of-range (too warm) and should not have been given to the resident. CDM stated the beverages should not have been left at the bedside. 1b. During a concurrent observation and interview on 1/27/25 at 1:15 p.m. in Resident 311's room with Licensed Vocational Nurse (LVN) 1, LVN 1, delivered Resident 311's lunch tray. Resident 311's meal ticket indicated the following: Puree, CCHO, (Consistent, Constant, or Controlled Carbohydrate) Fortified-Thick Fluids Nectar 8 Fl oz nectar drink punch 6 Fl oz SF hot chocolate -nectar 8 Fl oz water nectar-thick House nourishment: reduced sugar (chocolate) Resident 311's meal tray did not include 8 ounces fluid nectar-thick punch. LVN 1 stated there was no nectar-thick punch on the meal tray. During an interview on 1/28/25 at 8:25 a.m. with CDM, CDM stated she was aware the nectar-thick punch was not on Resident 311's meal tray for lunch. CDM stated, the necter-thick punch was missed in the kitchen. Resident 311's meal tray did not get checked when it went out of the kitchen. The meal tray should have been checked before it went out of the kitchen. The meal tray should have been checked before it got delivered to the resident. During a review of the facility's policy and procedure (P&P) titled, Therapeutic Diets, [undated], the P&P indicated, Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences .4. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to: 1. Honor resident's food preferences for two of 13 sampled residents (Resident 28, and Resident 51). This failure resulted i...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to: 1. Honor resident's food preferences for two of 13 sampled residents (Resident 28, and Resident 51). This failure resulted in an unpleasant dining experience due to the facility serving both Resident 28 and Resident 51 food listed as disliked and Resident 28 not receiving soup under her standing orders. 2. Ensure one of seven sampled residents (Resident 51) was aware of the menu in time to request an alternative menu item. This failure had the potential for Resident 51's nutritional needs to not be met. 3. Provide alternative milk product for one of one sampled residents (Resident 311) who had lactose (milk sugar) intolerance (unable to digest). This failure had the potential for Resident 311 to not meet his nutritional requirements. Findings: 1a.During a concurrent observation and interview on 1/27/25 at 12:42 p.m. with Resident 28 in the dining room, there were uneaten chili beans on Resident 28's meal tray. Resident 28 stated she disliked beans. Resident 28 stated, she had a standing order for chicken noodle soup, and she did not get chicken noodle soup for lunch. During a concurrent observation, interview, and record review on 1/27/25 at 12:54 p.m. in the dining room with Certified Dietary Manager (CDM), Resident 28's Meal Tray Ticket (MTT), dated 1/27/25, was reviewed. The MTT indicated, Standing orders for 1 bowl of chicken noodle soup and dislikes beans [no pinto or black]. CDM stated there were chili beans on Resident 28's meal tray. CDM stated she did not see chicken noodle soup on Resident 28's meal tray. CDM stated the facility was not honoring Resident 28's standing orders and dislikes as indicated on Resident 28's meal ticket. During a review of Resident 28's Minimum Data Set (MDS-Assessment Tool), dated 12/6/24, the MDS indicated Resident 28 had a (BIMS-Brief Interview for Mental Status) score of 15 (score of 13-15 means cognitively intact). During a review of Resident 28's Care Plan (CP), dated 11/20/24, the CP indicated, Focus: Resident 28 is at increased risk for weight loss and nutritional decline due to .modified diet. Interventions: LVN [Licensed Vocational Nurse] to check meal tray for accuracy to physician orders three times a day. During a review of the facility's policy and procedure (P&P) titled, Tray Identification, dated April 2007, the P&P indicated, 2. The food services manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. 3. Nursing staff shall check each food tray for the correct diet before serving the residents. During a review of the facility's P&P titled, TRAY CARD SYSTEM, dated 2023, the P&P indicated, PROCEDURE: The FNS [Food and Nutrition Service] Director is responsible for the tray card system. 1b. During a concurrent observation and interview on 1/27/25 at 1:30 p.m. in Resident 51's room with Resident 51, Resident 51's meal tray for lunch was served. Resident 51 had three-bean chili, tossed green salad with dressing, corn bread with green chilis and citrus fruit delight. Resident 51 stated, Look they served me three-bean chilis. This has tomatoes in it. During a review of Resident 51's meal ticket for dislikes, the following items were listed: fish, pork loin, tomato/tomato products (ketchup ok), soup, vegetables (bell pepper, broccoli, cauliflower, brussels, corn, peas, spinach), salads (lettuce, coleslaw), acidic foods (no citrus), spicy foods. During an interview on 1/28/25 at 8:20 a.m. with CDM, CDM stated yesterday's lunch was three-bean chilis. CDM stated the following were the ingredients for the dish: tomatoes, chili powder, beans, hamburgers, onions, and other spices. CDM stated [Resident 51] was served the three-bean chili with tomatoes. CDM stated, That was the choice I made because I knew she liked beans. I thought that would not be a problem. CDM stated she was aware she disliked tomato products. CDM stated. It was my mistake. 2. During a concurrent observation and interview on 1/27/25 at 11:26 a.m. in Resident 51's room, with Resident 51, Resident 51 was in bed, lying on an airflow mattress (specialty mattress to help prevent pressure sores). Resident 51 stated she was bed-bound and she had a lot of medical issues. Resident 51 stated sometimes she would just eat from the snack cart because she could not get an alternate meal if she did not like the food. Resident 51 stated the kitchen had certain rules that alternate food should be ordered within certain times. Resident 51 stated there was a one-hour rule and two-hour rule, and she got confused about those rules. Resident 51 stated she could not see the menu that was posted on the wall. Resident 51 stated, she was told she could no longer get an alternate food item because her request was recieved too late, and the kitchen would not accept the request for an alternative item. Resident 51 stated the only time she could order the alternate food was when the food was already served in her room, but the kitchen would not honor my request that late. During an interview on 1/28/25 at 8:04 a.m. with CDM, CDM stated Door 2 of the Kitchen was used for ordering alternate food. CDM stated there was a doorbell for the staff to alert the dietary staff. CDM stated the alternate menu and the regular menu for the day are also posted on the door. CDM stated there are specific times when the residents can order alternate food, at least one hour before lunch or dinner. The kitchen staff need at least one hour to prepare the food. 3. During an interview on 1/29/25 at 11:57 a.m. with CNA 3, CNA 3 stated Resident 311's breakfast tray included thickened hot cholate in a sippy cup. During an interview on 1/30/25 at 9:56 a.m. with CDM, CDM stated on the morning of 1/29/25, she was aware hot chocolate was still served to Resident 311 although the doctor ordered for lactose intolerance on 1/28/25. CDM stated, Yes hot chocolate was served; the hot chocolate packet contains dairy in it. CDM stated this morning the nurse notified her about Resident 311's lactose intolerance. During a review of Resident 311's Nursing Progress Notes (NPN), dated 1/28/25, the NPN indicated, The following orders were received from MD (doctor) per RD (registered dietitian) recommendation: #1 D/C (discontinue) HN (house nourishment, dairy based nutritional supplement) #2 Pro-Stat 30 ml .Dietary made aware of new orders . During a review of the Resident 311's Physician's Order (PO), dated 1/28/25, the PO indicated, D/C House Nourishment. Pro-Stat Oral Liquid (Amino-Acid Protein Hydrolysate) Give 30 ml by mouth two times a day for supplement. Mix with 60 ml of fluid. During a review of the facility's P&P titled, Menu Alternatives, [undated], the P&P indicated, An alternative meal or entrée and vegetable should be provided at every meal in the event of personal food preferences or refusals. 1 .The alternate must be offered to the resident in a timely manner and preferably within 20 minutes of refusal of the main course. Always available entrees, sandwiches, soups, salads, desserts planned by the resident help increase resident satisfaction .4. If a food is disliked, an appropriate equivalent substitution must be made. Alternative meals should be available with therapeutic extensions and recipes that are of equivalent nutritional value to the meals on the menu. During a review of the facility's P&P titled, Accommodation of Needs, dated 3/2021, the P&P indicated, 1. The resident's individual needs and preferences are accommodated to the extent possible.

CONCERN (D)

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

Deficiency F0912 (Tag F0912)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the minimum square footage as required by the ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the minimum square footage as required by the regulation for 11 of 50 of the facility rooms. Findings: During an observation on 1/29/25 at 12:04 p.m. in room [ROOM NUMBER], there were three residents in the room. Bed A had a wheelchair parked at the right side of the bed and Bed C had a wheelchair parked in form of the closet. During an observation on 1/29/25 at 3:14 p.m. in room [ROOM NUMBER], there were three residents in the room. Bed B had a walker and side table at the right side of the bed and Bed C had a side table to the right side of the bed. During a concurrent interview and record review on 1/30/25 at 8:42 a.m. with Administrator and Maintenance Supervisor (MS), the facility's Rooms Not Meeting Required Square Footage (RNMRSF), undated was reviewed. The RNMRSF indicated the following rooms did not provide the minimum square footage (Sq ft.) as require by regulation (80 Sq ft. per resident) for multiple resident rooms: room [ROOM NUMBER] 227.2 Sq ft. (3 residents) room [ROOM NUMBER] 219.2 Sq ft. (3 residents) room [ROOM NUMBER]-room [ROOM NUMBER] 2345 Sq ft. (3 residents) Administrator and MS stated the residents have not complained about the size of their rooms. Although the facility did not provide the minimum square footage as required by regulation, variations in the rooms. The rooms were in accordance with the particular needs of the residents. Closet and storage space was adequate. Bed stands were available. There was sufficient room for nursing care and for the residents to ambulate (move from place to place). The health and safety of the residents would not be affected by the waiver.

CONCERN (E)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Office of the State Long-Term Care Ombudsman (OSLTCO-in...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Office of the State Long-Term Care Ombudsman (OSLTCO-independent advocate who helps protect the rights of residents) a Notice of Transfer when: 1. Facility transferred three of three sampled residents (Resident 51, Resident 68, Resident 127) to a local hospital and 2. Facility discharged (transfer without expectation of return to facility) one of one sampled resident (Resident 159) to a local hospital. These failures denied Resident 51, Resident 68, Resident 127, and Resident 159 immediate access to an advocate who could inform of transfer or discharge options and resident rights. Findings: 1a. During an interview on 1/27/25 at 11:48 a.m. with Resident 51, Resident 51 stated she was hospitalized in June 2024 for abdominal (stomach) abscess (a collection of pus or infected fluid surrounded by inflamed tissue) that spread to her hips and legs. During a concurrent interview and record review on 1/30/25 at 10:23 a.m. with Assistant Director of Nursing (ADON), Resident 51's Situation, Background, Assessment, and Recommendation (SBAR communication tool) Communication dated 6/24/24, was reviewed. The SBAR indicated, Resident 51 was transferred to a local hospital. ADON stated Resident 51 was admitted for evaluation and management of fistula (abnormal connection between organs, intestine or skin). During an interview on 1/30/25 at 10:41 a.m. with Medical Records Director (MRD), MRD stated she was responsible for providing a written notification of transfer or discharge to OSLTCO. MRD stated she notified Ombudsman by facsimile. MRD stated, I do not have proof I notified Ombudsman. MRD was unable to provide evidence of the documents faxed or receipt of confirmation from the Ombudsman's office. MRD stated she did not have any records or documentation of notification of transfer to Ombudsman. MRD stated, I just do not have proof I received confirmation. I need to document in the medical records. During an interview on 1/30/25 at 10:47 a.m. with Social Services Director (SSD), SSD stated she prepared the notice of transfer and gave the documents to MRD. SSD was unable to provide copies of the written notice of transfer. During a concurrent interview and record review on 1/30/25 at 10:50 a.m. with ADON, Resident 51's Nursing Progress Notes (NPN), dated 6/24/24 was reviewed. ADON was unable to provide evidence of nursing documentation in the NPN of the nurse providing orientation and preparation of the resident prior to transfer. 1b. During a concurrent interview and record review on 1/30/25 at 3:15 p.m. with ADON, Resident's SBAR Communication, dated 1/25/25, was reviewed. The SBAR indicated, Resident 68 had a fall with injury. ADON stated Resident 68 was taken to the Emergency Department for evaluation of the laceration to the right side of the head. During an interview on 1/30/25 at 3:18 p.m. with MRD, MRD stated she had no record of a written notification to OSLTCO. During a concurrent interview and record review on 1/30/25 at 3:20 p.m. with ADON, Resident 68's, NPN, dated 1/25/25 was reviewed. ADON stated she was unable to find nursing documentation of an orientation and preparation of Resident 68's transfer to the acute care hospital. 1c. During an interview on 1/27/25 at 11:40 a.m. with Resident 127, Resident 127 stated he had been in and out of the hospital. Resident stated he was transferred to the hospital in December 2024. During a concurrent interview and record review on 1/29/25 at 4:45 p.m. with Licensed Vocational Nurse (LVN) 9, Resident 127's Nurse's Note (NN), dated 12/19/24 was reviewed. The NN indicated, upon assessment Resident 127 had crackles (noise in lungs) in the right lung, diminished (less than normal) breath sounds in the left lung with labored (difficulty) breathing. Resident 127 was on oxygen at 3 Liters per minute. The Medical Doctor was notified and gave a new order to Resident 127 to the hospital. Responsible Party notified. LVN 9 stated she notified MD of Resident 127's status. LVN 9 stated MD gave a verbal phone order to send Resident 127 out to hospital. During a review of Resident 127's, Change of Condition Evaluation (COC), dated 12/19/24, the COC indicated, Recommendation Primary Clinician send to Hospital. During a concurrent interview and record review on 1/29/25 at 3:35 p.m. with MRD, Resident 127's Medical Record (MR) was reviewed. MRD reviewed Resident 127's MR and MRD stated she could not find OSLTCO notice for Resident 127 transfer to hospital on [DATE] and stated she was not aware that she was supposed to notify the Ombudsman for hospital transfers. 2. During a review of Resident 159's COC, dated 11/24/24, the COC indicated, Recommendation Primary Clinician send to emergency room (ER) for Computerized Tomography -(CT diagnostic imaging scan). During a concurrent interview and record review on 1/29/25 at 3:41 p.m. with MRD, Resident 159's Face Sheet (FS),'' was reviewed. The FS indicated, Date of Discharge 11/24/24.discharged to Acute Care hospital. MRD stated, Yes. Resident 159 was discharged to the local hospital on [DATE]. During a concurrent interview and record review on 1/29/25 at 3:47 p.m. with MRD, Resident 159's MR was reviewed. MRD stated she could not find OSLTCO notice for Resident 159 transfer to hospital on [DATE]. MRD stated she was not aware that she was supposed to notify the Ombudsman for hospital transfers. During a review of the facility's policy and procedure (P&P) titled, Transfer or Discharge, Facility-Initiated, [undated], the P&P indicated, Notice of Transfer or Discharge (Emergent or Therapeutic Leave): 4. Notice of Transfer is provided to the resident and representative as soon as practicable before the transfer and to the Long-Term Care (LTC) Ombudsman when practicable (e.g. in a monthly list of residents that includes all notice content requirements) .7. Nursing notes will include documentation of appropriate orientation and preparation of the resident prior to transfer or discharge. During a review of the facility's P&P titled, Charting and Documentation, the P&P indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

CONCERN (E)

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

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to follow its policy & procedure (P&P) Binding Arbitration Agreement (BAA - a way to resolve disputes between healthcare providers and residen...

Read full inspector narrative →

Based on interview and record review, the facility failed to follow its policy & procedure (P&P) Binding Arbitration Agreement (BAA - a way to resolve disputes between healthcare providers and residents) for four of four sampled residents (Resident 62, Resident 134, Resident 101, and Resident 135) when: 1. admission Director (AD) did not explain the BAA to two of four sampled residents (Resident 62 and Resident 134) in a manner that he or she understood, before signing the agreement. 2. AD did not document a verbal acknowledgement of the BAA from four of four sampled residents (Resident 62, Resident 134, Resident 101, and Resident 135). This failure resulted in Resident 62, Resident 134, Resident 101, and Resident 135 not being fully aware and informed of their rights if there was a dispute with the facility. Findings: 1. During a concurrent interview and record review on 1/28/25 at 4:36 p.m. with Resident 62, Resident 62's, BAA form, dated 10/14/24 was reviewed. The BAA indicated, Resident 62 had signed the BAA form. Resident 62 stated he remembers signing the form but, he did not understand everything that was on the form. Resident 62 stated he did not remember anyone informing him that he was giving up his right to a jury. During a concurrent interview and record review on 1/29/25 at 8:42 a.m. with Resident 134, Resident 134's BAA form, dated 7/8/24 was reviewed. The BAA indicated, Resident 134 had signed the BAA form. Resident 134 stated he does not remember signing the arbitration form. Resident 134 stated he did not he recall anyone explaining the form to him. During a concurrent interview and record review on 1/29/25 at 8:48 a.m. with Admissions Director (AD), Resident 62's Brief Interview of Mental Status (BIMS-a tool used to screen and identify the cognitive condition of the residents upon admission using a point system that ranges from 0 to 15 points: 0 to 7 points-severe cognitive impairment. 8 to 12 points-moderate cognitive impairment. 13 to 15 points-cognition is intact). AD stated Resident 62's BIM score was 12. During a concurrent interview and record review on 1/29/25 at 8:52 a.m. with AD, Resident 134's BIMS was reviewed. AD stated Resident 134's BIM score indicated 15. 2. During a concurrent interview and record review on 1/29/25 at 8:54 a.m. with AD, Resident 62's Medical Record (MR), and BAA form were reviewed. AD stated she only had Resident 62 sign the BAA form. AD stated she did not document if the resident acknowledged or understood what they were signing. During a concurrent interview and record review on 1/29/25 at 8:55 a.m. with AD, Resident 134's MR and BAA form was reviewed. AD stated she only had Resident 134 sign the BAA form. AD stated she did not document if the resident acknowledged or understood what they were signing. During a concurrent interview and record review on 1/29/25 at 8:56 a.m. with AD, Resident 101's MR and BAA form was reviewed. AD stated she only had Resident 101 sign the BAA form. AD stated she did not document if the resident acknowledged or understood what they were signing. During a concurrent interview and record review on 1/29/25 at 8:57 a.m. with AD, Resident 135's MR and BAA form was reviewed. AD stated she only had Resident 135 sign the BAA form. AD stated she did not document if the resident acknowledged or understood what they were signing. During a review of the facility's P&P titled, Binding Arbitration Agreement, dated 2023, the P&P indicated, 5. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding.7. After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before asked to sign the document. a. A signature alone is not sufficient acknowledgement of understanding. B. The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement.

CONCERN (F)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure advance directives (AD- A legal document that states a perso...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure advance directives (AD- A legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) were offered and completed for 20 of 36 sampled residents (Resident 113, Resident 73, Resident 411, Resident 128, Resident 104, Resident 135, Resident 2, Resident 111, Resident 77, Resident 312, Resident 311, Resident 81, Resident 51, Resident 68, Resident 313, Resident 36, Resident 101, Resident 43, Resident 109, and Resident 84). This failure had the potential for residents' healthcare wishes to not be honored. Findings: During a concurrent interview and record review on 1/29/25 at 11:41 a.m. with Social Services Assistant (SSA), Resident 113 AD was reviewed. The AD indicated, 1. I have executed an Advanced Directive Yes blank No blank 2. I have provided the center a copy of my Advanced Directive Yes blank No blank 3. I will bring in a copy of the Advanced Directive for the medical record Yes blank No blank 4. I am interested in executing an Advanced Directive (refer to SSD [Social Services Department] Yes blank No blank.Signature Spoken (handwritten) Date blank admission Representative blank Date blank. SSA was unable to provide documentation that Resident 113 was offered an AD or had completed an AD. SSA stated there was no AD and there was no acknowledgment in Resident 113 medical record. During a concurrent interview and record review on 1/29/25 at 11:51 a.m. with SSA, SSA was unable to provide documentation of an AD for Resident 73. SSA stated Resident 73 did not have an AD and there was no acknowledgment in Resident 73's medical record. During a concurrent interview and record review on 1/29/25 at 11:54 a.m. with SSA, Resident 411's AD was reviewed. The AD indicated, 1. I have executed an Advanced Directive Yes blank No blank 2. I have provided the center a copy of my Advanced Directive Yes blank No blank 3. I will bring in a copy of the Advanced Directive for the medical record Yes blank No blank 4. I am interested in executing an Advanced Directive (refer to SSD [Social Services Department] Yes blank No blank.Signature Spoken (handwritten) Date blank admission Representative blank Date blank. SSA was unable to provide documentation of an AD for Resident 411. SSA stated Resident 411 did not have an AD and there was no acknowledgment in Resident 411's medical record. During a concurrent interview and record review on 1/29/25 at 3:07 p.m. with SSA, Patient 128's AD dated 7/15/24 was reviewed. The AD indicated, 1. I have executed an Advanced Directive Yes blank No blank 2. I have provided the center a copy of my Advanced Directive Yes blank No blank 3. I will bring in a copy of the Advanced Directive for the medical record Yes blank No blank 4. I am interested in executing an Advanced Directive (refer to SSD [Social Services Department] Yes blank No blank.Signature Spoken (handwritten) Date 7/15/24 admission Representative (illegible handwritten name) Date 5/21/24. SSA stated, Its incomplete. Yes [the AD] should have been completed. During a concurrent interview and record review on 1/29/25 at 2:11 p.m. with SSA, Resident 104's AD was reviewed. The AD indicated, 1. I have executed an Advanced Directive Yes blank No blank 2. I have provided the center a copy of my Advanced Directive Yes blank No blank 3. I will bring in a copy of the Advanced Directive for the medical record Yes blank No blank 4. I am interested in executing an Advanced Directive (refer to SSD [Social Services Department] Yes blank No blank.Signature Spoken (handwritten) Date blank admission Representative blank Date blank. SSA stated, It's [the AD is]incomplete. During a concurrent interview and record review on 1/29/25 at 2:16 p.m. with SSA, Resident 135's AD was reviewed. The AD indicated, 1. I have executed an Advanced Directive Yes blank No blank 2. I have provided the center a copy of my Advanced Directive Yes blank No blank 3. I will bring in a copy of the Advanced Directive for the medical record Yes blank No blank 4. I am interested in executing an Advanced Directive (refer to SSD [Social Services Department] Yes blank No blank.Signature [name] (handwritten) Date 8/29/24 admission Representative (illegible handwritten name) Date 8/7/24. SSA was unable to provide documentation of an AD for Resident 135. SSA stated, There is an AD but it's incomplete. During a concurrent interview and record review on 1/29/25 at 2:18 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 2. SSA stated, This one [Resident 2's medical record] doesn't have one [AD]. During a concurrent interview and record review on 1/29/25 at 2:20 p.m. with SSA, Resident 111's AD was reviewed. The AD indicated, 1. I have executed an Advanced Directive Yes blank No blank 2. I have provided the center a copy of my Advanced Directive Yes blank No blank 3. I will bring in a copy of the Advanced Directive for the medical record Yes blank No blank 4. I am interested in executing an Advanced Directive (refer to SSD [Social Services Department] Yes blank No blank.Signature Spoken (handwritten) Date blank admission Representative blank Date blank. SSA was unable to provide documentation of an AD for Resident 111. SSA stated, So this one is complete they signed it, but didn't say what they wanted [record is incomplete]. During a concurrent interview and record review on 1/29/25 at 2:22 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 77. SSA stated, He is back when we had matrix [charting system] before we switched to point-click-care [charting system] so either it didn't get transferred [record not found]. During a concurrent interview and record review on 1/29/25 at 2:27 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 312. SSA stated new admission no AD found. During a concurrent interview and record review on 1/29/25 at 2:27 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 311. SSA stated not signed or found in medical record. During a concurrent interview and record review on 1/29/25 at 2:28 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 81. SSA stated Does not have one. During a concurrent interview and record review on 1/29/25 at 2:30 p.m. with Medical Records Director (MRD), MRD was unable to provide documentation of an AD for Resident 51. MRD stated They don't have one. During a concurrent interview and record review on 1/29/25 at 2:33 p.m. with MRD, MRD was unable to provide documentation of an AD for Resident 68. MRD stated, No AD in the medical record. During a concurrent interview and record review on 1/29/25 at 2:37 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 313. SSA stated, So he is another one with a blank AD form. During a concurrent interview and record review on 1/29/25 at 2:40 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 36. SSA stated, So she is another one who didn't sign everything. During a concurrent interview and record review on 1/29/25 at 2:42 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 101. SSA stated he is one who did not click this [form] record incomplete. During a concurrent interview and record review on 1/29/25 at 2:44 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 43. SSA stated, He doesn't have one. During a concurrent interview and record review on 1/29/25 at 2:45 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 109. SSA stated no AD or request for AD form found in medical record. During a concurrent interview and record review on 2/3/25 at 12:12 p.m. with SSA, SSA was unable to provide documentation of an AD for Resident 84. SSA stated, She doesn't have an AD, and I can't pull it. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 2001, the P&P indicated, The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. b. Advance Directive - a written instruction, such as a living will or durable power of attorney for health care, recognized by state (weather statutory or as recognized by the courts of the state), relating to the provisions of health care when the individual is incapacitated. Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and /or his or her legal representative, about the existence of any written advance directives. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained and equipment was in good repair in accordance with professional standards for foo...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained and equipment was in good repair in accordance with professional standards for food service safety when: 1. The dishmachine and ice machine manufacturer's guidelines were not followed related to lack of a floor drain and lack of proper air gap to prevent the backflow of potentially contaminated water into the clean water supply. 2. Floor sink drains related to a steamer and hand washing sink were not maintained in a sanitary manner and in good repair in which pooled water could attract pests such as insects and rodents. 3. Clean foodservice equipment was stored on shelves with scattered dried food debris. 4. The foodservice operation lacked cleaning with detergent prior to sanitizing of food contact surfaces. These failures had the potential to result in cross contamination and foodborne illness for 159 highly susceptible residents receiving food from the kitchen. Findings: 1. During a concurrent observation and interview on 1/27/25 at 10:43 a.m. with Maintenance Supervisor (MS) in the kitchen, a small outlet was attached to the front of the dishmachine with no floor drain located underneath or near the dish machine. MS stated that was not a drain for wastewater and there was no floor drain because the air gap is plumbed into the wall and therefore the air gap was not visible. MS stated the dishmachine was installed via a dishmachine rental program by an outside vendor about two years ago. During a concurrent observation and interview on 1/27/25 at 11:22 a.m. with Certified Dietary Manager (CDM) in a hallway upon entrance to the kitchen (next to the janitorial/chemical closet), the ice machine did not have a drain or air gap. CDM stated it was a new ice machine. During a concurrent observation and interview on 1/29/25 at 9:19 a.m. with MS in the kitchen, no visual air gap or drain for the ice machine was seen. MS stated the water from the ice machine gets drained by a long pipe attached to the ice machine that was connected to and in which the water drains into, an evaporator (MS pointed to a blue colored machine/evaporator) that was connected to a black colored pipe (PVC pipe per MS) that was on the other side of a wall, located in the Janitorial/chemical closet, and the water flows out of the PVC pipe into pipes inside the wall and exits outside of the building into the sewage system. During a review of the ice machine manufacturer guidelines (IMMGs), undated, the IMMGs indicated, Ice Machine head connection diagram depicting the long drain hose going into the floor drain. The Drain hose installation.the water shall be prevented from flowing into the ice bin storage.the ice machine drains should be separated.the floor drain. During a review of the facility's policy and procedure (P&P) titled, Sanitation, dated 9/28/24, the P&P indicated, Policy.All equipment shall be maintained as necessary and kept in working order. Air Gaps/ Backflow prevention is included within Section 10 (page 10.5). During a review of the facility P&P titled, Accident Prevention- Safety Precautions, dated 9/28/24, the P&P indicated, Section 10.5.Backflow Prevention/Airgaps: If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. An air gap is the most reliable backflow prevention device. It is the physical separation of the potable and non-potable water supply systems by an air space. All steam tables, ice machines and bins, food preparation sinks, .and other equipment that discharge liquid waste or condensate shall be drained through an air gap into an open floor sink. During a review of the Food and Drug Administration Food Code (FDAFC), dated 2022, the FDAFC indicated, A plumbing system shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment.backflow prevention is required by law, by: (A) Providing an air gap. (FDA Food Code; 5-203.14). During a concurrent interview and record review on 1/29/25 at 9:30 a.m. with MS, the facility's Standard Dishmachine Rental Agreement (RA), dated 2/18/2022 was reviewed. The RA indicated, Customer is responsible for locating the hard water supply line and floor drain properly sized to accommodate backwash flow rates.For all equipment, Customer must provide plumbing and electrical hookups and any and all required governmental permits. MS stated he was unaware of the requirements listed in the RA. During a review of the FDAFC Annex (FDAFCA), dated 2022, the FDAFCA indicated, Improper repair or maintenance of any portion of the plumbing system may result in potential health hazards such as cross connections, backflow, or leakage. These conditions may result in the contamination of food, equipment, utensils. (FDA Food Code Annex; 5-205.15). 2. During a concurrent observation and interview on 1/27/25 at 10:57 a.m. with CDM in the kitchen, a floor sink drain located under a foodservice steamer was extensively covered in an orange-colored substance with the grout appearing with black thick grime and there was missing/cracked portions of the rim of the floor sink drain. CDM stated, I think that's rust. CDM stated the drain was not maintained in a sanitary manner and the lack of a smooth surface on the rim prevented adequate cleaning. During a concurrent observation and interview on 1/27/25 at 10:59 a.m. with CDM in the kitchen, a floor sink drain was full to the rim with standing pooled water (water was not draining). CDM stated the drain looked like that most of the time and the water would frequently overflow onto the kitchen floor. CDM stated it was unsanitary and had been like that for a long time with MS aware. CDM stated the drain was for a hand washing sink that was located on the other side of the wall at the nursing station. During a concurrent observation and interview on 1/29/25 at 9:36 a.m. with MS in the kitchen, the floor sink drain underneath the steamer had an extensive orange colored substance in and around the floor sink drain. MS stated, Appeared to be rust. MS stated the condition of the drain was not sanitary and should be a smooth surface for effective cleaning. MS stated that was not reported to him. During a concurrent observation and interview on 1/29/25 at 9:45 a.m. with MS in the kitchen, there was a floor sink drain, near the entrance of the kitchen from the door closest to the nursing station. MS stated he needed to put a scope down the drain to identify the problem. During a review of the facility's P&P titled, Sanitization, dated November 2022, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. During a review of the facility's P&P titled, Sanitation, dated 9/28/24, the P&P indicated, Policy.All equipment shall be maintained as necessary and kept in working order. The Maintenance Department will assist Food & Nutrition Services as necessary in maintaining equipment. During a review of the facility's P&P titled, General Cleaning of Food & Nutrition Services Department, dated 9/28/24, the P&P indicated, Drains; Floor drains must be scheduled for routine cleaning in order to be maintained in a functional condition. 1. FNS staff should remove large debris as it accumulates and are encouraged to clean drains weekly. 2. The Maintenance Department will assist with more thorough cleanings to ensure the viability of the plumbing features. During a review of the FDAFCA, dated 2022, FDAFCA indicated, Liquid wastes need to be quickly carried away to prevent pooling which could attract pests such as insects and rodents. (FDA Food Code Annex; Chapter 6; Physical Facilities). During record review of FDAFC, dated 2022, the FDAFC indicated, A plumbing system shall be: Maintained in good repair, and Physical facilities shall be maintained in good repair. (FDA Food Code 5-205.15 and 6-501.11). 3. During a concurrent observation and interview on 1/27/25 at 10:52 a.m. with CDM in the kitchen, clean bowls and plates were stored on two shelves in which food debris was scattered amongst the shelves on top of the mesh, and the outside of the stainless-steel cabinet had extensive orange colored substance. CDM stated the orange colored substance was rust and the food debris scattered among clean dishes was unsanitary. During an observation on 1/27/25 at 11:08 a.m. in the kitchen, there was food debris on top of pots that were stored faced down, located underneath a food preparation counter where a toaster was located. During a review of the facility's P&P titled, Sanitization, dated 2022, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean. 4. During an observation on 1/28/25 at 10:52 a.m. in the kitchen, staff was using a cloth obtained from a sanitizing solution located in a red bucket to sanitize food contact surfaces. During an observation on 1/28/25 at 11:30 a.m. in the kitchen, three empty meal delivery carts had white spots on them and scattered dried food debris and were available for use for the lunch meal service. During an interview on 1/28/25 at 4:30 p.m. with CDM, CDM stated she did not like to use green detergent buckets to wash food contact surfaces first because it takes too long to dry, and then staff would have to use the sanitizing solution after the wash with detergent step, and then wait for the sanitizer to dry. CDM stated she has not incorporated a wash with detergent step before sanitizing within the foodservice operation for any purpose other than dish washing. CDM stated, the carts and food preparation counters do not really get dirty anyway so sanitizing them cleans them as well. During a review of the facility's P&P titled, Sanitization, dated 2022, the P&P indicated, Policy Statement: The food service area is maintained in a clean and sanitary manner. 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. During a review of the facility's P&P titled, Sanitation, dated 9/28/24, the P&P indicated, The FNS [Food & Nutrition Services] Director is responsible for instructing employees in the fundamentals of sanitation in food service and for training employees to use appropriate techniques. The FNS Director is responsible for selecting and ordering all necessary equipment for the Food & Nutrition Services Department. The FNSD will also consult with the Administrator and Facility Registered Dietitian, as necessary. During a review of the facility's P&P titled, Kitchen Sanitation: Definition of Terms: Standards of cleanliness need to be defined in order to clearly understand the types and scope of procedures to be used in the Food & Nutrition Services Department.Cleaning: Removal of soil, particles, debris, and microorganisms adherent to surface. Procedure: Scrubbing with hot water and detergent.Sanitation: Process that reduces the number of microorganisms on utensils is to a relatively safe level. During a review of the FDAFCA, dated 2022, the FDAFCA indicated, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. The objective of cleaning focuses on the need to remove organic matter from foodcontact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. (FDA Food Code Annex; 4-601.11). During a review of the FDAFCA, dated 2022, the FDAFCA indicated, Pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. They may also be passed on by consumers or employees directly, or indirectly from used tableware or food containers. Some pathogenic microorganisms survive outside the body for considerable periods of time. Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contamination. (FDA Food Code Annex; 3-304.11 Food Contact with Equipment and Utensils). During a review of the FDAFCA, dated 2022, the FDAFCA indicated, Wiping down a surface with a reusable wet cloth that has been properly stored in a sanitizer solution is an acceptable practice for wiping up certain types of food spills and wiping down equipment surfaces. However, this practice does not constitute cleaning and sanitizing of food contact surfaces where and when such is required to satisfy the methods and frequency requirements in Parts 4-6 and 4-7 of the Food Code. (FDA Food Code Annex, 3-304.14) During a review of the facility's job description (JD) titled Dietary Manager, [undated], the JD indicated, Maintain kitchen and food storage area in a safe, orderly, clean and sanitary manner. During a review of the facility's JD titled Maintenance Supervisor, [undated], the JD indicated, Coordinate maintenance services and activities with other related departments (i.e., Dietary, Nursing, Activities, etc.), Ensure that services performed by outside vendors are properly completed/supervised in accordance with contracts/work orders.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to follow infection control policies and procedures (P&P) as evidenced by: 1. Licensed Vocational Nurse (LVN) did not follow the facility P&P)...

Read full inspector narrative →

Based on interview and record review, the facility failed to follow infection control policies and procedures (P&P) as evidenced by: 1. Licensed Vocational Nurse (LVN) did not follow the facility P&P) titled Administering Medications to administer medications in a clean and sanitary manner for two of two residents (Resident 66 and Resident 143). This failure had the potential to result in infection and illness for Resident 55 and Resident 143. 2. Infection Preventionist (IPN), did not follow the facility P&P titled Surveillance for Infection and Monitoring Compliance with Infection Control for surveillance (monitoring) activities, collecting, analyzing, track and trending of data. This failure had the potential for facility to be unaware of outbreaks and the transmission of infectious diseases. 3. Nursing Staff did not follow the facility P&P titled Department (Respiratory Therapy) - Prevention of Infection.) for dating, storage and discarding of tubing for one of one sampled residents' (Resident 1) respiratory tubing. 4. Housekeeping (HK) staff did not follow the facility P&P titled Housekeeping and janitorial Procedures for two of three housekeeping carts when housekeepers stored a used toilet brush in the clean area of the housekeeping cart. This failure had the potential to spread infections to residents, staff, and visitors. Findings: 1. During an observation on 1/29/25 at 8:35 a.m. with LVN 4, LVN 4 touched Resident 143's Sertraline (used in the treatment of depression) 50 mg (milligram - unit of measurement) one tablet and Alprazolam (used in treatment of anxiety) 0.25 mg one tablet with ungloved hands and placed the pills into the pill cup. During an observation on 1/29/25 at 8:39 a.m. with LVN 4, LVN 4 touched Resident 66's Lorazepam (used in the treatment for anxiety) 1 mg one tablet with ungloved hands. During an interview on 1/29/25 at 8:42 a.m. with LVN 4, LVN 4 stated, I should make sure it [the medication] goes into the cup and not use my hands. During an interview on 1/29/25 at 3:20 p.m. or of Nursing (DON), DON stated, No we should not touch the pill it should be popped into the pill cup. During a review of the facility's policy and procedure (P&P) titled, Administering Medications dated 2001, the P&P indicated, Policy Statement Medications are to be administered in a safe and timely manner. 25. Staff follows established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves isolation precautions, etc.) for the administration of medications, as applicable. 2. During a concurrent interview and record review on 2/3/25 at 11:40 a.m. with IPN, the facility's surveillance activities for infection control were reviewed. IPN stated the surveillance activities for Infection Control included the following: hand hygiene, blood glucose, transmission-based precaution on donning and doffing, Personal Protective Equipment (PPE-protective clothing or devices) and disposing of contaminated items. IPN stated surveillance on hand hygiene was conducted weekly. IPN stated, I walk around and talk to the staff. I pick different people: doctor, social services, nursing staff, and whoever is going out of the resident's room. I observe to see what the staff was doing and if I find something wrong, I fix it, so it does not continue. During a concurrent interview and record review on 2/3/25 at 12 p.m. with IPN, Hand Hygiene Surveillance (HHS), dated 6/6/24, 6/11/24, 6/19/24, and 6/25/24, were reviewed. The HHS indicated the following: 6/6/24: Adherence rate 65% 6/11/24: Adherence rate 70% 6/19/24: Adherence rate: 75% 6/25/24: Adherence rate: 65% The reviewed HHS did not indicate the time when the surveillance was conducted, and the actions taken to correct non-compliance. IPN stated she talked to the staff, but she had no record of just-in-time education. IPN stated she only collected data. IPN was unable to provide documentation of track and trending of reports, analysis of the surveillance data, or actions taken to correct non-compliance. During a review of the facility's policy and procedure (P&P) titled, Surveillance for Infection, dated 9/2017, the P&P indicated, Gathering Surveillance Data: The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data . Interpreting Surveillance Data: 1. Analyze the data to identify trends . b. Consider how increases or decreases might relate to recent process changes, events or activities in the facility. Trends should be monitored . Surveillance data will be provided to the Infection Control Committee regularly. The Infection Control Committee will determine how important surveillance data will be communicated to the physicians and other providers, Administrator, nursing units. During a review of the facility's P&P titled, Monitoring Compliance with Infection Control dated 8/2019, the P&P indicated, 1. The infection preventionist or designee monitors the compliance and effectiveness of our infection prevention and control policies and procedures. 2. Monitoring includes regular surveillance to hand hygiene practices and availability of hand hygiene supplies and the availability of personal protective equipment and its appropriate use .4. Compliance surveillance is unannounced. 3. During an observation on 1/27/25 at 10:27 a.m. in Resident 2's room, there was an unlabeled Inhalation breathing treatment (INH) tubing and medication revisor at bedside. During a concurrent interview and record review on 1/27/25 at 11:33 a.m. with LVN 5, Resident 2's Medication Administration Record (MAR), dated 1/2025,the MAR indicated, an order for Ipratropium-Albuterol (medication to open airways and make breathing easier) Solution 0.5-2.5 mg/3ml [milligrams per milliliters, dosage], 3 ml inhale orally every 4 hours as needed for SOB (shortness of breath) or wheezing via (delivery) nebulizer, dated 12/2/24. LVN 4 stated the process was for tubing to be new. LVN 4 stated Resident 2's last treatment was on 1/16/25 [11 days ago]. During an interview on 1/29/25 at 11:34 a.m. with IPN, IPN stated the process for INH tubing is to be changed every seven days and placed in a bag dated and labeled. During a review of the facility's P&P titled, Department (Respiratory Therapy) - Prevention of Infection.) dated 11/2011, the P&P indicated, Discard the administration set-up every (7) days. 4. During a concurrent observation and interview on 1/29/25 at 2:29 p.m. with Housekeeping (HK) 1 in station three hallway, the housekeeping cart had a used toilet brush stored at the bottom of the housekeeping cart. The used toilet brush was stored next to four unopened boxes of gloves and roll of paper towel in a bag. HK 1 stated she used the toilet brush under the cart. HK 1 stated the toilet brush should not be with the unopened boxes of gloves. During a concurrent observation and interview on 1/29/25 at 2:34 p.m. with HK 2 in station two hallway, the housekeeping cart had a used toilet brush stored at the bottom of the housekeeping cart. The used toilet brush was stored next to five unopened boxes of gloves. HK 2 stated he has used the toilet brush. HK 2 stated the toilet brush should not be with the unopened boxes of gloves. During an interview on 1/29/25 at 2:35 p.m. with HD, HD stated the used toilet brush should not be stored with the unopened boxes of gloves. During an interview on 1/29/25 at 2:43 p.m. with IPN, IPN stated used toilet brushes should not have been stored with unopened boxes of gloves. During an interview on 1/29/25 at 3:59 p.m. with Infection Prevention Nurse Consultant (IPNC), IPNC stated used toilet brushes should not be stored with unopened boxes of gloves. During a review of the facility's P&P titled, HOUSEKEEPING AND JANITORIAL PROCEDURES, [undated], the P&P indicated, POLICIES: It is the policy of this facility to provide a clean, safe, orderly, comfortable, and attractive environment for both residents and guest.

CONCERN (F)

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

Deficiency F0943 (Tag F0943)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse [inappropriate treatment of an individual], Neglect [refusal to provide the needs of th...

Read full inspector narrative →

Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Abuse [inappropriate treatment of an individual], Neglect [refusal to provide the needs of the resident], Exploitation [taking improper advantage of an individual], and Misappropriation [misuse, stealing from a resident] Prevention Program, annual training for the following: 1. 17 of 73 sampled Certified Nursing Assistants (CNA), CNA 1, CNA 2, CNA 33, CNA 4, CNA 5, CNA 6, CNA 7, CNA 8, CNA 9, CNA 10, CNA 11, CNA 12, CNA 13, CNA 14, CNA 15, CNA 16, and CNA 17), 2. Seven of thirty one sampled Licensed Vocational Nurses (LVN), LVN 4, LVN 15, LVN 6, LVN 10, LVN 8, LVN 19, LVN 100, 3. Four of twelve sampled Dietary Aids (DA), DA 1, DA 2, DA 3, DA 4, 4. Two of four sampled cooks, [NAME] 1, [NAME] 2, 5. Two of twenty Feeding Assistants (FA) FA 1, FA 2, 6. One of three sampled Speech Language Pathologist (SLP) SLP, 7. One of two sampled Respiratory Therapist (RT) 1, 8. One of six sampled Restorative Nursing Assistants (RNA) 1, 9. Two of three sampled Occupational Therapist (OT) 1 and OT 2, 10. One of one sampled Minimum Data Set Coordinator (MDSC), and 11. One of seven sampled Registered Nurses (RN) 2. This failure had the potential for staff to be unaware of what constituted abuse, the reporting requirements and therefore abuse in residents to go unnoticed and unreported within the facility. Findings: During a concurrent interview and record review on 1/29/25 at 9:15 a.m. with Director of Staff Development (DSD), the facility's annual training record on Your Legal Duty: Reporting Elder and Dependent Adult Abuse (YLD), dated 1/24/25 through 1/20/25, was reviewed. The YLD record indicated the following facility staff had not received the annual training: 1. CNA 1, no documented training. CNA 2, no documented training. CNA 33, no documented training. CNA 4, no documented training. CNA 5, no documented training. CNA 6, no documented training. CNA 7, no documented training. CNA 8, no documented training. CNA 9, no documented training. CNA 10, no documented training. CNA 11, no documented training. CNA 12, no documented training. CNA 13, no documented training. CNA 14, no documented training. CNA 15, no documented training. CNA 16, no documented training. CNA 17, no documented training. 2. LVN 4, no documented training. LVN 15, no documented training. LVN 6, no documented training. LVN 10, no documented training. LVN 8, no documented training. LVN 19, no documented training. LVN 100, no documented training. 3. DA 1, no documented training. DA 2, no documented training. DA 3, no documented training. DA 4, no documented training. 4. [NAME] 1, no documented training. Cook 2, no documented training. 5. SLP, no documented training. 6. RT 1, no documented training. 7. RNA 1, no documented training. 8. OT 1, no documented training. 9. MDSC, no documented training. 10. RN 2, no documented training. DSD stated staff had not attended make-up sessions of training. No additional documentation was provided. During a review of the facility's P&P titled, Abuse, Neglect, Exploration and Misappropriation Prevention Program, dated 4/2021, the P&P indicated, Provide staff orientation and training.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) call light was within Resident 1's easy reach. This failure had the potenti...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) call light was within Resident 1's easy reach. This failure had the potential for Resident 1 to not received assistance when needed. Findings: During a concurrent observation and interview on 10/2/24, at 12:10 p.m. in Resident 1's room, Resident 1's call light (a communication device used to alert staff for assistance) was noted on the floor not within Resident 1's reach. Resident 1 stated he uses the call light to call for staff assistance. Resident 1 started looking for his call light, using his hands to feel under his back, bottom area, above head, and on the bed side rails. Resident 1 was unable to locate his call light. Resident 1 stated, Oh well, it's not here. During a concurrent observation and interview on 10/2/24, at 12:17 p.m. with Certified Nursing Assistant (CNA 1), in Resident 1's room, CNA 1 confirmed Resident 1's call light was on the floor not within Resident 1's reach. CNA 1 stated Resident 1's call light should always be within reach. During an interview with on 10/2/24, at 12:36 p.m. with Licensed Vocational Nurse (LVN), LVN stated Resident 1 were able to use the call light for assistance if the call light was within his reach. LVN stated Resident 1's call light should always be near him and within reach. During an interview on 10/2/24, at 1:16 p.m. with CNA 2, CNA 2 stated she had laid Resident 2 back to bed after being up in his wheelchair. CNA 2 stated she had forgot to ensure Resident 1's call light was near him and within reach. CNA 2 stated the call light should always be within reach. During an interview on 10/2/24, at 1:22 p.m. with Director of Nurses (DON), DON stated call light should be placed within reach. During a review of the facility's policy and procedure (P&P) titled, Call System, Residents, dated 9/22, the P&P indicated, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.

Aug 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 F0837 (Tag F0837)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak of scabies (a contagious, intensely itchy skin condition caused by a tiny, burrow...

Read full inspector narrative →

Based on interview and record review, the facility failed to implement its policy and procedure (P&P) when an outbreak of scabies (a contagious, intensely itchy skin condition caused by a tiny, burrowing mite) was not reported to the state health department for three of fourteen sampled residents (Resident 1, Resident 2, and Resident 3). This failure resulted in the state health department being unaware of the outbreak. Findings: During a review of Resident 1 ' s Integumentary Assessment Sheet (IAS), dated 8/8/24, the IAS indicated, Pt (patient) seen exam bedside with generalized pruritic (having or causing itching) maculopapular (flat, discolored area of skin and raised bumps) rash with some tracking without burrowing and ddx (differential diagnosis) scabies. During a review of Resident 2 ' s IAS, dated 8/8/24, the IAS indicated, Pt seen exam bedside with generalized pruritic rash tracking to trunk and upper extremities and ddx of scabies. During a review of Resident 3 ' s IAS, dated 8/8/24, the IAS indicated, Pt seen exam bedside with generalized pruritic maculopapular rash tracking to trunk/upper extremities with ddx of scabies. During an interview on 8/15/24 at 12:57 p.m. with Infection Preventionist (IP), IP stated on 8/8/24, Resident 1, Resident 2, and Resident 3, were clinically diagnosed with scabies by the wound doctor. During an interview on 8/15/24 at 1:23 p.m. with the Treatment Nurse (TN), TN stated on 8/8/24, Resident 1, Resident 2, and Resident 3, were clinically diagnosed with scabies by the wound doctor. During an interview on 8/15/24 at 1:46 p.m. with Director of Nursing (DON), DON stated on 8/8/24, Resident 1, Resident 2, and Resident 3, were clinically diagnosed with scabies by the wound doctor. DON stated IP reported the scabies to the local health department but did not report it to the state health department. During a review of the California Department of Public Health Prevention and Control of Scabies in California Healthcare Setting dated 8/2020, the guidance indicated, An outbreak should be assumed to be occurring following diagnosis of a single case, until screening of all new patients and staff for scabies has been completed without identifying additional suspect cases. An outbreak cannot be conclusively excluded for at least 6 weeks following the last unprotected exposure to the case. During a review of the facility ' s policy and procedure (P&P) titled Outbreak of Communicable Diseases dated 9/22, the P&P indicated, An outbreak is defined as one of the following.One case of an infection that is highly communicable or has serious health implications.Occurrence of three (3) or more cases of the same infection over a specified period of time and in a defined area.The administrator is responsible for.communicating data about reportable diseases to the health department. During a review of the facility ' s policy and procedure (P&P) titled Reportable Diseases dated 9/22, the P&P indicated, Reportable diseases are infections, illnesses or conditions with public health significance that must be reported to the local and/or state health department.

Jun 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) referral was made for one of two...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure a psychiatrist (medical practitioner specializing in the diagnosis and treatment of mental illness) referral was made for one of two sampled residents (Resident 1). This failure resulted in a delay of the psychiatrist evaluation for Resident 1. Findings: During a review of Resident 1's Psychologist Consultation/Follow-Up (PCF), dated 4/9/24, the PCF indicated, Resident alert with confusion, has tendency to wander take others property believing it is hers, behaviors increase at night. Consider re-starting Seroquel (medication used to treat several kinds of mental health conditions) . During a review of Resident 1's IDT (interdisciplinary team-knowledge from different health care disciplines to help people receive the care they need) Psychotherapeutic Review (IPR), dated 4/12/24, the IPR indicated, IDT does not agree with considering to re start medication used prior to admission. IDT recommends that (Resident 1) be referred to a psychiatrist for further evaluation. IDT reviewed recommendations with (Primary MD) who agrees with plan. During a review of Resident 1's Progress Notes (PN), dated 4/11/24, the PN indicated, Resident was seen by facility psych (psychologist-a person who studies the human mind, emotion, and behavior) on 4/9/24.recommendation to consider restarting the Seroquel.IDT at this time does not agree with psych recommendation, feels resident may need to be seen by a psychiatrist first. During a concurrent interview and record review, on 6/28/24 at 11:22 p.m. with Social Service Director (SSD), SSD reviewed Resident 1's clinical record. There was no psychiatrist evaluation completed. SSD stated at the time the recommendation was made the facility did not have a psychiatrist and Resident 1 was not referred out. During an interview on 6/28/24 at 12:12 p.m. with Director of Nursing (DON), DON stated Resident 1 should have been referred to a psychiatrist. During a review of the facility's policy and procedure (P&P) titled, Referrals, Social Services dated 12/08, the P&P indicated, Social services shall coordinate most resident referrals.Referrals for medical services must be based on physician evaluation.Social services will collaborate with the nursing staff or other pertinent disciplines to arrange for services that have been ordered by the physician.Social services will document the referral in the resident's medical record.

May 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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of three sampled residents (Resident 1) when the bed linen was not in good repair. Thi...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to provide a homelike environment for one of three sampled residents (Resident 1) when the bed linen was not in good repair. This failure resulted in Resident 1's bed sheet having a hole and two areas where the sheet was discolored due to the thinning of the sheet. Findings: During a concurrent observation and interview on 5/16/24 at 12:15 p.m. with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 had a hole at the bottom of her bed sheet and an area of discoloration caused by thin and tattered threads on the side of the bed sheet. CNA 1 stated the sheet was thinning and identified the hole at the bottom of the sheet. During a concurrent observation and interview on 5/16/24 at 1 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 1's room, Resident 1 had two areas on her bottom bed sheet that were thinning and discolored. LVN 1 stated the sheets were thin, and it was causing the discolored areas. During an interview on 5/29/24 at 12:29 p.m. with Director of Nursing (DON), DON stated when the bed sheets contained holes and were discolored, they should have not been used. During a review of the facility's policy and procedure (P&P) titled, Bed, making an unoccupied dated 2/18, the P&P indicated, The purpose of this procedure is to provide the resident who is able to get out of bed with a clean, comfortable bed.Protecting the resident's skin.Do not use torn linen.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) when a Family Member (FM) 1 made Licensed Vocational Nurse (L...

Read full inspector narrative →

Based on interview and record review, the facility failed to report an allegation of abuse for one of three sampled residents (Resident 1) when a Family Member (FM) 1 made Licensed Vocational Nurse (LVN) 1 aware of the allegation of abuse. This failure had the potential for delayed investigation and place other residents at risk for abuse. Findings: During an interview on 5/16/24 at 8:40 a.m. with FM 1, FM 1 stated over the weekend (approximately 4-5 days earlier), she reported to Licensed Vocational Nurse (LVN) 1 every time a male staff (unidentified) walked by Resident 1 would say he hits me. During an interview on 5/16/24 at 11:56 a.m. with LVN 1, LVN 1 stated When there is an allegation of abuse the allegation was to be reported (to the management) right away. During an interview on 5/16/24 at 1 p.m. with LVN 1, LVN 1 stated approximately two weeks ago, Resident 1's FM had reported to her Resident 1 seemed upset when a male staff would work with her. Resident 1 would say the male staff would hit her. LVN 1 stated she did not report the allegation. During an interview on 5/16/24 at 1:08 p.m. with LVN 2, LVN 2 stated when an allegation of abuse was reported, an SOC 341 (form used to report suspected dependent adult/elder abuse) was to be completed, social services, the police department, California Department of Public Health (CDPH) and the Ombudsman were to be notified immediately or as soon as possible. During an interview on 5/16/24 at 1:16 p.m. with Director of Nursing (DON), DON stated there was no allegations of abuse reported recently. DON stated when an allegation of abuse was made, the staff were expected to complete an SOC 341 right away and an abuse investigation was to be initiated. During an interview on 5/16/24 at 1:35 p.m. with Social Service Director (SSD), SSD stated she was not made aware of any allegation of abuse. During a concurrent interview and record review on 6/5/24 at 4:33 p.m. with DON, the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating dated 9/22, the P&P indicated, All reports of resident abuse.are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management.If resident abuse.is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law.Immediately is defined as.within two hours of an allegation involving abuse. DON stated the staff member should have followed the facility policy and procedure and reported the allegation of abuse.

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 F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide podiatry services for two of three sampled residents (Resident 1 and Resident 2). This failure resulted in Resident 1...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to provide podiatry services for two of three sampled residents (Resident 1 and Resident 2). This failure resulted in Resident 1 and Resident 2 having long, jagged, discolored toenails. Findings: a. During an observation on 5/16/24 at 12:03 p.m. in the hallway, Resident 2 was walking in the hallway with opened toe sandals. Resident 2's toenails were long and discolored. During a review of Resident 2's Order Summary Report (OSR) dated 5/20/24, the OSR indicated, Consult – Podiatry as needed for Mycotic (disease caused by a fungus)/Hypertrophic (alteration of shape, partial loss, or absence of the nail) nails and/or keratotic (patches or lesions on the outer layer of the skin) lesions.order date 2/13/23. During a concurrent interview and record review on 5/16/24 at 2:21 p.m. with Director of Nursing (DON), DON reviewed Resident 2's clinical record and was unable to provide evidence Resident 2 had received podiatry care. DON stated the facility staff does not provide toenail care and relies on the podiatrist. b. During a review of Resident 1's Podiatry Progress Note (PN) dated 8/19/23 (approximately 9 months prior), the PN indicated, Follow up.2 months. During a review of Resident 1's Shower Sheets (SS) dated 4/5/24, 4/23/24, 4/30/24, 5/3/24, 5/10/24, the SS indicated, Toe Nails.Needs Clipping.Yes. During an observation and interview on 5/16/24 at 12:15 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 1's room, Resident 1 was lying on the bed. Resident 1 had long toenails, some with jagged edges and there were debris under them. CNA 1 stated CNAs were not allowed to trim the resident's toenails. During an interview on 5/16/24 at 12:38 p.m. with LVN 1, LVN 1 stated podiatry services were responsible for resident toenails and Resident 1 needed to be seen by podiatry. During an interview on 5/16/24 at 1:35 p.m. with Social Service Director (SSD), SSD stated nursing staff was responsible to report to social services when residents needed podiatry services. SSD stated Resident 1 was last seen by podiatry in August 2023. During an interview on 5/21/24 at 9:39 a.m. with DON, DON stated when he observed Resident 1 and Resident 2's feet both residents had long toenails and they didn't look good. DON stated both residents needed podiatry services. During a review of the facility's policy and procedure (P&P) titled, Foot Care dated 10/22, the P&P indicated, Residents are provided with foot care and treatment.overall foot care includes the care and treatment of medical conditions to prevent foot complications.Residents are assisted in making appointments and with transportation to and from specialists (podiatrist.) as needed.

May 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to notify the physician in a timely manner when one of three sampled resident's (Resident 1) continued to experience a change in condition. Th...

Read full inspector narrative →

Based on interview and record review, the facility failed to notify the physician in a timely manner when one of three sampled resident's (Resident 1) continued to experience a change in condition. This failure resulted in a delay of care. Findings: During a review of Resident 1's ED [Emergency Department] Note Physician (EDNP), dated 2/2/24 at 4:02 p.m. the EDNP indicated, Chief Complaint.Abdominal pain.Final Diagnosis.Abdominal Pain.Nausea.Hx (history) of gastric bypass (weight loss surgery).small bowel obstruction (digested material is prevented from passing normally through the bowel). During a review of Resident 1's Progress Notes (PN), dated 1/31/24 at 3 p.m. the PN indicated, Resident had 2 episodes of emesis (vomiting) and meal refusal for breakfast and lunch. Resident complained of abd (abdominal) pain to left upper quadrant and mid abdomen. Placed call to [Physician 1] and gave new orders: Stat (immediately) CBC (complete blood count-measures many different parts and features of the blood) & CMP (comprehensive metabolic panel-provides important information about balance of chemicals in the body) & ammonia (produced in the body by the bacteria in the intestines, ammonia levels rise when the liver is not functioning properly). Also a stat (immediately or without delay) abdominal xray.Resident will be on monitor for emesis and abd (abdominal) pain. During a review of the Patient Report (PR), reported 1/31/24 at 6:03 p.m. the PR indicated, Impressions.There is an.air-filled and slightly dilated loop of large bowel which appears to represent the ascending (first section of colon) colon and hepatic (relating to the liver) flexure (bent or curved part) of undetermined significance. This may represent an adynamic ileus (functional motor paralysis of the digestive tract secondary to neuromuscular failure). During a review of Resident 1's PN, dated 1/31/24 at 11:55 p.m. the PN indicated, Text [Physician 1] abd. Xray report. Messaged [Physician 1] to call facility with any new orders. During a review of Resident 1's PN, dated 2/1/24 at 12:17 a.m. the PN indicated, Resident has had no episodes of vomiting tonight, was nauseated earlier and refused 2000 (8 p.m.) meds (medications). Taking fluids well. Pending abdominal xray. Labs in A.M. will f/u (follow up) with M.D. (Physician) when results available. During a review of Resident 1's PN, dated 2/2/24 at 1:35 a.m. (approximately 34 hours after onset of symptoms), the PN indicated, Resident has had 2 episodes of N/V (nausea and vomiting) tonight given Zofran (medication used to treat nausea and vomiting) and is effective for a short time and then res (resident) gets nausea again. Vomiting clear liquid, approx. (approximately) ½ cup.To have AM nurse f/u with [Physician 1] as this cont (continues). During a review of Resident 1's Weekly Summary (WS), dated 2/2/24 at 1:51 a.m. the WS indicated, Resident has had multiple episodes of N/V (nausea and vomiting). Has had abd (abdominal) xray. [Physician 1] received results on 2/1/24 waiting on any new orders. To have AM nurse f/u (follow up) today as N/V continues. During a review of Resident 1's PN, dated 2/2/24 at 3:10 p.m. (approximately 48 hours after onset of symptoms), the PN indicated, Resident continues to have episodes of N/V x3 today. [Physician 1] has been informed and awaiting for further orders. During a review of Resident 1's PN, dated 2/2/24 at 4:02 p.m. the PN indicated, Received new order from [Physician 1] to send resident out to rule out small obstruction. During a review of Resident 1's PN dated 2/2/24 at 11:45 pm. the PN indicated, Per RN (registered nurse), resident was still being evaluated but was most likely going to be admitted to hospital for bowel obstruction. During a concurrent interview and record review, on 5/7/24 at 3:39 p.m. with Director of Nursing (DON), DON reviewed Resident 1's PN's. DON stated when Resident 1 continued to have nausea on 2/2 at 1:35 a.m. and the medication was not working, the physician should have been notified. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status dated 2/21, the P&P indicated, The nurse will notify the resident's attending physician.when there has been a(an).need to alter the resident's medical treatment significantly.A significant change of condition is a major decline or improvement in the resident's status that.will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions.

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

Based on interview and record review, the facility failed to ensure wound treatments were provided for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's woun...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure wound treatments were provided for one of three sampled residents (Resident 1). This failure had the potential for Resident 1's wounds to worsen. Findings: During a review of Resident 1's Treatment Administration Record (TAR), dated January 2024, the TAR indicated, Monitor right heel diabetic ulcer (serious complication caused by a combination of poor circulation, susceptibility to infection and nerve damage from high blood sugar levels) daily for 1. Pain/discomfort, 2. s/s (signs and symptoms) of infection. Every day shift.start date 1/12/24.Monitor right lower back stage 3 (full thickness tissue loss wound caused by pressure) daily for 1. Pain/discomfort, 2. s/s of infection. Every day shift.start date 1/12/24.Monitor sacrococcygeal (base of the spine near the tailbone) DTI (deep tissue injury) daily for 1. Pain/discomfort, 2. s/s of infection. Every day shift.start date 1/12/24.Right heel diabetic ulcer treatment: wipe with betadine swab. Every day.start date 1/11/24.Right lower back stage 3 treatment: Cleanse with N/S (normal saline), pat dry apply Collagen (structural protein found in skin and other connective tissues) fiber & medihoney manuka (medication used to treat wounds) pad and cover with dry dressing. Every day shift.start date 1/12/24.Sacrococcygeal DTI (deep tissue injury) treatment: Cleanse with N/S, pat dry, apply skin prep and cover with foam dressing, every day shift every Mon, Wed, Sat for DTI.start date 1.13/24.Apply heel/foot protectors to bilateral feet while in bed every shift for monitor placement.start date 1/23/24.Dycem in which to prevent resident from sliding off. Monitor placement. Every shift for prevent sliding.start date 1/13/24.LAL (low air loss) mattress. Set to resident's weight. Check to ensure proper placement and function. To promote skin integrity. Every shift for mattress check.start date 1/11/24. The TAR was blank (indicating the treatment was not done) on 1/13/24, 1/14/24, 1/15/24, 1/19/24, 1/22/24, 1/23/24, 1/24/24, 1/27/27. During a concurrent interview and record review on 5/29/24 at 3:59 p.m. with Assistant Director of Nursing (ADON), ADON reviewed the TAR dated 1/24. ADON stated confirmed the findings and stated when the treatment was completed, the nurse should have documented it on the TAR. During a review of the facility's policy and procedure (P&P) titled Wound care dated 10/10, the P&P indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing.The following information should be recorded in the resident's medical record.The type of wound care given.the date and time the wound care was given.the name and title of the individual performing the wound care.the signature and title of the person recording the data.

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

Based on interview and record review, the facility failed to ensure bowel movement (BM) documentations were completed for one of three sampled residents (Resident 1). This failure resulted in incomple...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure bowel movement (BM) documentations were completed for one of three sampled residents (Resident 1). This failure resulted in incomplete documentation. Findings: During a concurrent interview and record review with Director of Nursing (DON), on 5/30/24 at 12 p.m. Resident 1's BM Report (BMR), undated, was reviewed. The BMR indicated, Resident 1 had no BM documentation on 1/15 and was incontinent of BM on 1/10, 1/11, 1/13, and 1/16. There was no consistency or size of BM documented on 1/10, 1/11, 1/13 and 1/16. DON stated the BM documentations were incomplete. DON stated the size and consistency of the BM should have been documented. During an interview on 5/7/24 at 12:30 p.m. with Director of Staff Development (DSD), DSD stated she was responsible for training the staff on how to document BM's. DSD stated the staff should have documented whether the resident was continent or incontinent, the consistency of the BM and the size. During a review of the facility's policy and procedure (P&P) titled, Bowel Management Protocol dated 2/15/15, the P&P indicated, CNA's (Certified Nursing Assistant) to document the number of bowel movements and size of bowel movements on the resident flow record.

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided sup...

Read full inspector narrative →

**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 provided supervision when staff failed to respond to a security door alarm going off in the dementia (progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking) unit. This resulted in Resident 1 exiting the open security gate that provided access off of the facility grounds and being found approximately a quarter of a mile away from the facility. Findings: During a review of Resident 1's Plan of Care (POC), dated 8/22/22, the POC indicated, Elopement Care Plan. [Resident 1] is at risk for elopement/exiting seeking due to: altered cognitive status (dementia).date initiated: 8/22/22.interventions.monitor resident's whereabouts frequently.provide redirection to resident as needed. During a review of Resident 1's admission Record (AR), dated 2/14/24, the AR indicated, admission Date 3/13/2018.Diagnosis Information.Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic (loss of reality) disturbance, mood disturbance, and anxiety (nervousness or unease).Altered mental status, unspecified, Bipolar Disorder (episodes of mood swings ranging from depressive lows to manic highs), unspecified.Schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of metal fragmentation), unspecified.Nicotine Dependence, cigarettes, uncomplicated.wandering in diseases classified elsewhere. During a review of Resident 1's Elopement Risk Observation/Assessment (EROA), dated 1/10/24, the EROA indicated, Category: At risk for Elopement.Score: 10.The resident.is fully ambulatory. During a review of Resident 1's Cognitive Patterns (CP), dated 1/11/24, the CP indicated, BIMS (Brief Interview for Mental Status) Summary Score.02 (indicating severe cognitive impairment) During a review of Resident 1's Change in condition (COC), dated 2/13/24, the COC indicated, list the other change: Elopement.This started on: 2/13/24.resident has history of exit seeking.Primary Diagnosis.unspecified dementia). During a review of Resident 1's Progress Notes (PN), dated 2/14/24, the PN indicated, Per nurses noted date 2/13/24 @ (at) 1950 (7:50 p.m.); writer starting med(medication)-pass when alarm starts to go off, CNA (Certified Nursing Assistant) goes to turn it off when they notice that the resident was nowhere to be seen. Last seen in hallway a [sic] approximately at 1920 (7:20 p.m.) after code [NAME] was called on the overhead, staff searching the facility grounds, administrator DON was notified of missing resident including responsible party and the local police department.received call from DON approximately at 1950 (7:50 p.m.) that resident was found and retrieved by administrator.Upon return tothe [sic] facility [Resident 1] stated he was going to the store to buy some cigarettes and weed. During an interview on 2/27/24 at 10:14 a.m., with Patio Aide (PA) 1, PA 1 stated, Resident 1 will try and leave the facility if he does not get to smoke when he wants to smoke. PA 1 stated cigarettes are left during the night with the nurse so Resident 1 can smoke during the night. PA 1 stated there is no patio aide available after 7 p.m. PA 1 stated there were two security door alarms on the dementia unit and both provide access to the parking lot. PA 1 stated when the security doors are pushed, the alarm will sound and then the doors open in about 12-15 seconds. During an interview on 2/27/24 at 10:28 a.m., with CNA 1, CNA 1 stated when Resident 1 does not get his way he will start exit seeking. CNA 1 stated the security gate alarms can be heard inside the unit and it was the responsibility of all staff to respond to the alarm when it is going off. During an interview on 2/27/24 at 10:32 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when Resident 1 did not get to smoke when he requested it, he gets mad and looks for ways out of the dementia unit. LVN 1 stated Resident 1 was fast and would open the security doors to go to the front of the facility when he was upset. LVN 1 stated Resident 1 was constantly pushing on the doors to go out. LVN 1 stated when the security door alarms go off, it was everyone's responsibility to respond. LVN 1 stated Resident 1 was not to be outside without supervision. During an interview on 3/12/24 at 2:34 p.m., with Administrator, Administrator stated on 2/13/24, she was notified by staff Resident 1 could not be located on facility grounds. As she was driving to the facility, she saw Resident 1 on the left side of the road approximately a quarter of a mile away from the facility. Administrator stated she approached Resident 1 and was able to get him in the car and return him to the facility. Administrator stated when she returned Resident 1 to the facility, the service gate entrance was open and that is where Resident 1 had left the facility. Administrator stated the service gate was not working at the time Resident 1 eloped. Administrator stated the service gate had a sensor that would open/close the gate, the sensor was not functioning due to a past accident. Administrator stated the service gate leads to a busy street in front of the facility, and it was normally kept closed for safety. During an interview on 3/12/24 at 3:13 p.m., with Maintenance Director (MD), MD stated at the time Resident 1 eloped from the facility, the service gate was not functioning, and it was unable to close. MD stated the service gate was normally closed for resident safety. During an interview on 3/12/24 at 9:19 p.m., with LVN 2, LVN 2 stated she was assigned to Resident 1 on the night he eloped. LVN 2 stated the security door alarm was ringing and ringing (unsure of length of time) and by the time someone went to go check on it, they (staff) realized Resident 1 had gotten further than the security doors. LVN 2 stated the back yard, and the parking lot were searched, a code [NAME] (alerts staff there is a missing resident) was called, police and administration were notified. LVN 2 stated during the search for Resident 1, it was noted the service gate had not been repaired and was left open. LVN 2 stated Resident 1 walked fast and was able to leave facility grounds through the service gate entrance. LVN 2 stated when Resident 1 requested a cigarette, prior to the security door alarm sounding, she was unable to give him the cigarette at that time and that is when he got upset and left the facility. LVN 2 stated when the security door alarms are sounding, the staff are expected to stop what they are doing and check to see why they are going off. LVN 2 stated when the alarm was sounding, she could not leave her medication cart unattended because at the time the medication cart could not be secured. During an interview on 3/12/24 at 9:36 p.m., with CNA 2, CNA 2 stated she was assigned to Resident 1 the night he eloped. CNA 2 stated she was providing care to another resident when the security alarms were sounding. CNA 2 stated it took her approximately two to three minutes to respond to the alarm because she was busy providing care to another resident. CNA 2 stated Resident 1 was already outside going to the back when she finished providing care to another resident. CNA 2 stated she looked everywhere for Resident 1 and was told the back gate (service gate) was open in the front of the facility. CNA 2 stated she came back into the facility to get a sweater and continued to search. CNA 2 stated Resident 1 only gets up out of bed when he wants a cigarette. CNA 2 stated Resident 1 walked fast and always tried to leave the facility when he did not get a cigarette. CNA 2 stated it was all the staff's responsibility to respond to the alarm. During an interview on 3/13/24 at 11:04 a.m., with Director of Nursing (DON), DON stated it was the expectation of the staff to respond to the security door alarms right away. During an interview on 3/16/24 at 9:57 p.m., with CNA 3, CNA 3 stated she was working on the night Resident 1 eloped. CNA 3 stated she was aware of the security alarm going off but was providing resident care. CNA 3 stated she thought someone else had gone after Resident 1. CNA 3 stated when the alarm goes off it means the resident was at the door and the door will open in a few seconds allowing the resident off the unit. CNA 3 stated when the security alarms go off staff are supposed to run to the door. CNA 3 stated Resident 1 would wake up in the middle of the night to smoke and when he did not get a cigarette, he would try to leave the facility. CNA 3 stated Resident 1 was not safe to leave the facility and Resident 1 was found outside the facility walking down the street, it was bad. During an interview on 3/16/24 at 10:07 p.m., with CNA 4, CNA 4 stated on the night of the elopement he was doing rounds and suddenly heard the security alarm going off. He then was told Resident 1 was missing. CNA 4 stated when he heard the alarm sounding he was far from the side of the unit where the alarm was sounding and he did not respond. CNA 4 stated when Resident 1 wanted a cigarette, he would attempt to leave the facility if he did not get it. CNA 4 stated the security alarm was going off for approximately a minute to a minute and a half. Resident 1 was too quick, and when looking for him they could no longer find him, because he had gone too far. CNA 4 stated when the security alarms go off everyone should respond. During an interview on 3/16/24 at 10:15 p.m., with CNA 5, CNA 5 stated when the security alarms go off staff are supposed to respond right away. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents dated 7/17, the P&P indicated, Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision an assistive devices.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided a safe environment when there was exposed staples from a miss...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided a safe environment when there was exposed staples from a missing drawer face on Resident 1 ' s night stand. This failure had the potential for Resident 1 to be injured by the exposed staples. Findings: During a concurrent observation and interview, on 1/12/24 at 11:22 a.m., with Certified Nursing Assistant (CNA) 1, in Resident 1 ' s room, there was a nightstand at the head of Resident 1 ' s bed. The face of the top drawer was missing and there was exposed staple legs on the right side, where the face was supposed to be attached. CNA 1 stated, she noticed the face of the drawer was missing a few weeks ago, when she returned from her days off. CNA 1 stated, when items need to be repaired, they are supposed to write them in the maintenance log at the nurses station. CNA 1 stated, when she returned everyone was aware, so she did not put it in the maintenance log. During a concurrent interview and record review, on 1/12/24 at 11:41 a.m., with Licensed Vocational Nurse 1, LVN 1 reviewed the maintenance log and was unable to find Resident 1 ' s nightstand documented repair request. During an interview on 1/12/24 at 11:44 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, she seen Resident 1 ' s face of the drawer missing yesterday but did not put it in the maintenance log. LVN 2 stated, she should have documented it in the maintenance log. During an interview on 1/12/24 at 11:51 a.m., with Maintenance Assistant (MA), MA stated, maintenance was not aware Resident 1 ' s nightstand needed to be repaired. MA stated, when items need repaired, the staff were expected to document it in the maintenance log. During a review of the facility ' s policy and procedure (P&P) titled, Maintenance Services dated 12/2009, the P&P indicated, The maintenance Department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times.

Jan 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the responsible party (RP) was notified when medication was ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the responsible party (RP) was notified when medication was discontinued for one of three residents (Resident 1). This failure resulted in the RP being unaware of a change in Resident 1 ' s medical care. Findings: During a review of Resident 1 ' s Medication Administration Record (MAR), dated 11/23, the MAR indicated, Quetiapine Fumarate (used to treat mental health condition) Tablet 50mg (milligrams-unit of measure) take 1 tablet by mouth at bedtime. The MAR indicated the medication was last administered 11/15/23. During a review of Resident 1 ' s Progress Notes (PN), dated 11/14/23 at 11:27 a.m., the PN indicated, IDT (Interdisciplinary Team-a group of health care professionals with various areas of expertise who work together toward the goals of their clients) Note.Resident was admitted to the facility on [DATE] at which time he was receiving Quetiapine.Since his admission, resident has displayed no episodes of delusional thinking, therefore, team recommends contacting MD (physician) for possible d/c (discontinue) of Quetiapine. MD was contacted and in agreement with d/c of Quetiapine. Nursing notified to follow up with new order. During a concurrent interview and record review on 1/10/24, at 1:59 p.m., with Director of Nursing (DON), Resident 1 ' s clinical record was reviewed. DON was unable to provide evidence the RP was notified of the discontinuation of the Quetiapine Fumarate. DON stated, the RP should have been notified when the Quetiapine Fumarate was discontinued. During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status revised 2/21, the P&P indicated, Except in medical emergencies, notifications will be made within twenty-flour (24) hours of a change occurring in the resident ' s medical/mental condition or status.

Dec 2023 9 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

2. During an interview on 12/5/23 at 3:16 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, I have attempted to get him [Resident 73] to brush his teeth, but he refuses. We should keep tryi...

Read full inspector narrative →

2. During an interview on 12/5/23 at 3:16 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated, I have attempted to get him [Resident 73] to brush his teeth, but he refuses. We should keep trying if he refuses. During a review of Resident 73's Minimum Data Set (MDS-assessment tool), dated 11/20/23, the MDS indicated, Resident 73 had a BIMS (Brief Interview for Mental Status Score) of 00 (score of 0-7 means severely impaired.) During a review of Resident 73's MDS section E (Behavior) dated 11/20/23, the MDS indicated, Resident 73's Rejection of Care-Presence and Frequency. Behavior was not exhibited. During a review of Resident 73's MDS section G (Functional Status) dated 7/24/23, the MDS indicated, Resident 73's Assessment of Personal Hygiene-how resident maintains personal hygiene: Self-performance-extensive assistance. Support provided-one personal physical assist. During a concurrent interview and record review on 12/6/23 at 3:57 p.m. with Licensed Vocational Nurse (LVN) 10, Resident 73's CP dated 2023 was reviewed. LVN 10 stated Resident 73 does not have a CP for refusal of care. LVN 10 stated he (Resident 73) should have a refusal care plan. During a review of the facilities policy and procedure (P&P), titled Care Plans, Comprehensive Person-Centered, (undated), the P&P indicated, The comprehensive, person centered care plan should: . b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments). Based on interview and record review, the facility failed to develop for 3 of 66 sampled residents' (Resident 136, Resident 73, and Resident 24) an individualized care plans when: 1. Resident 136 did not have an activities Care Plan (CP). 2. Resident 73 did not have a refusal CP. 3. Resident 24 did not have a CP indicating the use of bedrails. These failures had the potential for Resident's to not receive care specific to their preference or choice. Findings: 1. During a review of Resident 136's Progress Notes (PN), dated 11/17/23 at 5:00 p.m. the PN indicated, [Family Member (FM)] provided with room number and informed [Resident 136] currently has no roommates. [FM] expressed concern regarding resident [Resident 136] being in room without doing any activities to keep him busy. During concurrent interview and record review on 12/7/23 at 9:46 a.m. with Director of Activities (DOA), Resident 136's Care Plans (CP), were reviewed. DOA stated there was no activities CP for Resident 136. During a review of Resident 136's Activities Assessment (AA), dated 6/12/23, the AA indicated it was Very important to Resident 136 to keep up with the news and do favorite activities. During a review of the facility's policy and procedure (P&P) titled, Activity Evaluation, dated February 2023, the P&P indicated, . 7. Each resident's activities care plan relates to his/her comprehensive assessment and reflects his/her individual needs. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, (undated), the P&P indicated, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. 1. A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT [team of care providers], with input from the resident, and his/her family or legal representative. 3. During an observation on 12/6/23 at 8:34 a.m. inside Resident 24's room, two bedside rails were observed in the upright position at the head of Resident 24's bed. During a concurrent interview and record review on 12/7/23 at 11:22 a.m. with LVN 11, LVN 11 reviewed the Electronic Medical Record (EMR) for Resident 24 and was unable to provide documented evidence of a physician's order being completed for the two side rails. LVN 11 stated, I don't see it referring to the physician order for bedside rails. During a concurrent interview and record review on 12/7/23 at 11:45 a.m. with the Director of Nursing (DON), DON reviewed the Electronic Medical Record (EMR) for Resident 24. DON was unable to provide documented evidence of a care plan having been completed regarding Resident 24's bedside rails. DON stated, No there is not one [CP]. During a review of the facility's policy and procedure (P&P) tilted, Care Plans, Comprehensive Person-Centered undated, the P&P indicated, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical and functional needs . 1. A comprehensive, person-centered care plan should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative .

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Follow physician's orders (PO) for one of 66 samp...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Follow physician's orders (PO) for one of 66 sampled resident's (Resident 129) when Resident 129's blood sugars (BS) were not monitored and documented. This failure had the potential to result in unmet care needs and adversely affect resident's health. 2. Obtain a physician's order for one of 66 sampled resident's (Resident 120) when Resident 120 was administering oxygen (O2 A chemical element needed to breath) to himself. This failure had the potential for Resident 120 to receive the incorrect dose of oxygenation, which can adversely affect her health condition. 3. Obtain a physician's order for bedside rails for one of 66 sampled resident's (Resident 24). This failure had the potential to result in injuries and unmet care needs. Findings: 1. During a review of Resident 129's admission Record (AR), dated 12/7/23, the AR indicated, Resident 129 was admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes Mellitus (DM high blood sugar) without complications. During a review of Resident 129's PO, dated 12/7/23, the PO indicated, Blood sugar check daily and as needed. May use earlobes. In the morning for DM2 [Diabetes Mellitus type 2] notify MD immediately if blood sugar < [less than] 60 or > [greater than] 400 and as needed for S/S [signs and symptoms] of hypo (low)/Hyperglycemia) high blood sugar notify MD immediately if blood sugar <60 or >400. During a review of Resident 129's Diabetic Administration Record (DAR), dated 12/7/23, the DAR indicated, BS [blood sugar] check daily and as needed for DM2 notify MD immediately if [BS] <60 or >400. During a concurrent interview and record review on 12/7/23 at 9:29 a.m. with Director of Nurses (DON), Resident 129's DAR dated 12/7/23 was reviewed. The DAR indicated, on 12/1/23, 12/2/23, 12/3/23, 12/4/23 for 6 a.m. administration time, there were initials from the licensed staff that BS's were completed. No BS results were documented for those dates. DON confirmed the findings and stated there is no documentation of the BS results and the Licensed Vocational Nurse's (LVN's) should be documenting the results. During a concurrent interview and record review on 12/7/23 at 9:30 a.m. with DON, Resident 129's Weights and Vitals Summary report (WVSR), dated 12/7/23 was reviewed. The WVSR indicated the last BS result documented for Resident 129 was on 10/18/23. DON stated, The last blood sugar that I can find was on 10/18/23. DON stated, They [LVN] did the blood sugar check, they should have documented it. During a review of the facility's policy and procedure (P&P) titled, Nursing Care of the Older Adult with Diabetes Mellitus, dated 2020, the P&P indicated, Blood Glucose Monitoring follow the provider orders for blood glucose monitoring. 2. During a concurrent observation and interview on 12/5/23 at 9:52 a.m. with Resident 120 in Resident 120's room, there was an oxygen concentrator seen in the resident's room. Resident 120 stated he only uses oxygen when he needs it. During a review of Resident 120's admission Record (AR), dated 12/6/23, the AR indicated, Resident 120 was admitted to the facility on [DATE] with diagnosis of Unspecified Sequelae of Cerebral Infarction (stroke). During a concurrent observation and interview on 12/6/23 at 12:30 p.m. with LVN 8, in Resident 120's room, an oxygen concentrator was sitting on the floor next to Resident 120's bed. Resident 120 was not using oxygen at the time of observation. Resident 120 stated he only uses it when he needs it and the last time he used it was two nights ago. LVN 8 stated she would review Resident 120's oxygen orders. During a concurrent interview and record review on 12/6/23 at 12:40 p.m. with LVN 8, Resident 120's PO's were reviewed. LVN 8 stated she was not able to find a PO for O2, and was not sure why the O2 was in Resident 120's room. LVN 8 stated Resident 120 needs a PO for O2 use. During a review of Resident 120's Brief Interview for Mental Status (BIMS), dated 9/18/23, the BIMS indicated, Resident 120's score was 12, (a score 8 to 12 moderate impairment or 13 to 15 intact cognitive response). During a review of the facility's policy and procedure (P&P) titled Oxygen Administration, dated 2010, the P&P indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 3. During an observation on 12/6/23 at 8:34 a.m. inside Resident 24's room, two bedside rails were noted in the upright position at the head of Resident 24's bed. During a concurrent interview and record review on 12/7/23 at 11:22 a.m. with LVN 11, LVN 11 reviewed the Electronic Medical Record (EMR) for Resident 24 and was unable to provide documented evidence of a Physician's Order (PO) being completed for the two side rails. LVN 11 stated, I don't see it referring to the physician order for bedside rails. During a concurrent interview and record review on 12/7/23 at 11:45 a.m. with DON, Resident 24's PO, dated 12/2023 was reviewed. DON stated, Yes, they get a physician order for the side rails, we do not have it, [and] should have it. During a review of the facility's policy and procedure (P&P) titled Bed Safety and Bed Rails dated 2022, the P&P indicated, Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met.3. The use of bed rails or side rails (including permanently raising the side rails for episode use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluations, resident assessment, and informed consent. 5.d. consultation with the attending physician.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents (Resident 73) was assisted with oral care. This failure resulted in Resident 73 having den...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents (Resident 73) was assisted with oral care. This failure resulted in Resident 73 having dental issues and tooth decay. Findings: During an interview on 12/5/23 at 1:00 p.m. with Responsible Party (RP) 1, RP1 stated, Prior to admission he [Resident 73] had a full set of his own teeth, and now the front teeth are chipping. During an observation on 12/5/23 at 3:16 p.m. in Resident 73's room, Resident 73's teeth had plaque (A sticky film that coats teeth and contains bacteria. Dental plaque can damage a tooth and lead to tooth decay or tooth loss. Regular brushing can help prevent plaque) build up, a yellowish discoloration, and chipped upper front teeth. During a concurrent observation and interview on 12/5/23 at 3:19 p.m. with Certified Nursing (CNA) 2, in Resident 73's room, Resident 73's teeth had plaque buildup, a yellow discoloration and chipped upper front teeth. CNA 2 stated, No his [Resident 73] teeth do not look clean, I have attempted [to brush], but he refuses. During a concurrent observation and interview on 12/6/23 at 3:49 p.m. with Resident 73, in Resident 73's room, Resident 73's teeth were yellow, discolored, plaque build up to teeth, upper front teeth are chipped. Resident 73 stated he had not brushed his teeth today. Resident 73 stated he would like to brush his teeth and can do it if staff help him. During a concurrent observation and interview on 12/6/23, at 3:57 p.m. with Licensed Vocational Nurse (LVN) 10, in Resident 73's room, LVN 10 confirmed Resident 73's teeth had plaque buildup and yellowish discoloration. LVN 10 stated, the CNAs should be doing oral care. If he [Resident 73] refuses we would try to offer oral care muliple times, not just once. During a concurrent observation and interview on 12/7/23 at 3:15 p.m. in station 4's hallway, Resident 73 was observed propelling himself down the hallway via a wheelchair. Resident 73's teeth were covered with plaque buildup and a yellow discoloration. Resident 73 stated he has not brushed his teeth today and yes, he would like to brush his teeth. During a review of Resident 73's MDS (Minimum data set - assessment tool), section G (Functional Status) dated 7/24/23, the MDS indicated, Resident 73's Assessment of Personal Hygiene-how resident maintains personal hygiene: Self-performance-extensive assistance. Support provided-one person physical assist. During a review of the facilities policy and procedure (P&P), titled Activities of Daily Living (ADL's), Supporting, dated March 2018, the P&P 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.

CONCERN (D)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day, seven day per week. This failu...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day, seven day per week. This failure had the potential to adversely affect resident care. Findings: During an interview on 12/6/23 at 8:45 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she is not sure if there is an RN who works on the floor eight hours per day. During an interview on 12/6/23 at 9:03 a.m. with LVN 2, LVN 2 stated, We only have [DON-Director of Nursing], we don't have any other RN who works in this facility. During an interview on 12/6/23 at 9:17 a.m. with LVN 3, LVN 3 stated, [DON] is the only RN that I am aware of that works in this facility. During an interview on 12/6/23 at 9:27 a.m. with LVN 4, LVN 4 stated Monday through Friday they have the DON. LVN 4 stated there is a part time RN who works occasionally, but there is no RN coverage on weekends. During an interview on 12/6/23 at 9:35 a.m. with LVN 7, LVN 7 stated there are no RN's working in the facility except for the DON. During an interview on 12/6/23 at 3:44 p.m. with Scheduling Coordinator (SC), SC stated, I'm gonna be honest, we don't have an RN that works a consecutive 8 hours per day seven days per week. SC stated the facility had one RN who occasionally works. During a concurrent interview and record review on 12/7/23 at 12:10 p.m. with DON, RN 1's Human Resources Timesheet (HRT) was reviewed. The HRT indicated, RN 1 worked in the facility on 9/1/23 and 9/19/23. DON reviewed RN 1's timesheet and stated RN 1 is the only RN currently working for this facility and rarely picks up any shifts. DON stated this facility does not have an RN that works eight consecutive hours per day, seven days per week. DON stated, Yes, this facility should have an RN. During a review of the facility's policy and procedure (P&P) titled, Staffing and Sufficient Nursing, dated August 2022, the P&P indicated, Sufficient Staff.3. A registered nurse provides services at least eight (8) consecutive hours every 24 hours, seven (7) days a week.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents' (Resident 136) was placed on contact precautions after receiving a contagious infection d...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents' (Resident 136) was placed on contact precautions after receiving a contagious infection diagnosis. This failure had the potential to result in the spread of infection to residents, staff and visitors. Findings: During an observation on 12/5/23 at 8:43 a.m. in Resident 136's room, Resident 136 was laying in bed on his right side, with blankets pulled up to his chin and both feet sticking out. Resident 136's feet were covered with multiple raised red bumps. During a review of Resident 136's Minimum Data Set (MDS-assessment tool), Section C Cognitive Patterns, dated 9/8/23, the MDS indicated Resident 136 had a Brief Interview of Mental Status (BIMS) score of 0, indicating Resident 136 was severely cognitively (mentally) impaired (score of 0-7 suggests severe cognitive impairment). During a review of Resident 136's Care Plan (CP), dated 11/9/23, the CP indicated Resident 136 had been diagnosed with Scabies (skin infection with severe itching caused by burrowing mites). Interventions included keeping Resident 136 in a private room by himself and with contact precautions. Resident 136 was placed in a private room on 11/22/23. During a concurrent interview and record review on 12/7/23 at 10:48 a.m. with Infection Preventionist (IP), Resident 136's Progress Notes (PN), dated 11/14/23 at 2:40 p.m. was reviewed. The PN indicated Resident 136 was placed on contact precautions. IP stated Resident 136 was diagnosed with Scabies on 11/9/23 but was not placed on contact precautions until 11/14/23. During an interview on 12/7/23 at 12:10 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she cared for Resident 136 on 11/9/23 when he returned from a doctor's appointment that afternoon. LVN 1 stated Resident 136 returned to the facility with a diagnosis of Scabies. LVN 1 stated she did not put Resident 136 on contact precautions or notify the IP. During a concurrent interview and record review on 12/7/23 at 2:11 p.m. with IP, Resident 136's clinical record was reviewed. The clinical record indicated the isolation stop sign was activated on Resident 136's clinical record on 11/14/23. IP stated the isolation stop sign in placed on a resident's clinical record when resident is placed in isolation for a transmissible infection. IP stated she activated the isolation stop sign on Resident 136's clinical record on 11/14/23. During an interview on 12/7/23 at 2:39 p.m. with Director of Nursing (DON), the DON stated contact precautions for Resident 136 should have started on 11/9/23. During a review if the facility's policy and procedure (P&P) titled, Isolation - Initiating Transmission-Based Precautions, dated August 2019, the P&P indicated, Transmission-Based Precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. 1. If a resident is suspected of, or identified as, having a communicable infectious disease, the Charge Nurse or Nursing Supervisor notifies the Infection Preventionist and the resident's Attending Physician for evaluation of appropriate Transmission-Based Precautions. 2. Transmission-based precautions are utilized when a resident meets the criteria for a transmissible infection AND the resident has risk factors that increase the likelihood of transmission. c. Cognitive deficits that restrict or interfere with the resident's ability to maintain precautions.

CONCERN (D)

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

Deficiency F0912 (Tag F0912)

Could have caused harm · This affected 1 resident

Based on observation and interview, this facility failed to provide the minimum square footage as required by the regulation in 50 of the facility bedrooms. Findings: During a concurrent observation a...

Read full inspector narrative →

Based on observation and interview, this facility failed to provide the minimum square footage as required by the regulation in 50 of the facility bedrooms. Findings: During a concurrent observation and interview on 12/5/23 at 9 a.m. with Administrator and Maintenance Supervisor (MS) in the facility, the following rooms did not provide the minimum square footage (sq. ft) as required by regulation (80 sq. ft. per resident) for multiple resident rooms: 1,2,3,5,6,7,8,9,10,11,18,19,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63. Administrator stated the residents have not complained about in the room size. Although the facility did not provide the minimum square footage as required by regulation, variations in the rooms. the rooms were in accordance with the particular needs of the residents. Closet and storage space was adequate. Bed stands were available. There was sufficient room for nursing care and for the residents to ambulate. The health and safety of the residents would not be affected by the waiver.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents (Resident 42) call light system was properly working. This failure had the potential for R...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one of 66 sampled residents (Resident 42) call light system was properly working. This failure had the potential for Resident 42's care needs to be unmet. Findings: During a concurrent observation and interview on 12/5/23 at 8:17 a.m. with Resident 42, in Resident 42's room, Resident 42 stated the call light had not been working for three days. Resident 42 pressed her call light and the light outside of Resident 42's room did not come on. During a concurrent observation and interview on 12/5/23 at 8:19 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 42's room, CNA 1 pushed Resident 42's call light button and the light outside of Resident 42's room did not come on. CNA 1 unplugged and plugged the call light cord back into the wall connection. CNA 1 stated the call lights plug was not pushed in. CNA 1 stated Resident 42 and her roommate both have their own call light cord, but they share the wall outlet that the cords plug into. CNA 1 stated sometimes when they give patient care to Resident 42's roommate and move the bed up or down it unplugs Resident 42's call light. CNA 1 stated they are always having to check to make sure her call light is plugged in after doing resident care. CNA 1 stated Resident 42 usually tells them when it is not working. During a concurrent observation and interview on 12/5/23 at 9:15 a.m. with Licensed Vocational Nurse (LVN) 9 in Resident 42's room, LVN 9 pressed Resident 42's call light and stated it was not working and that call lights should be working at all times. During a concurrent interview and record review on 12/7/23 at 2:50 p.m. with LVN 3, Nursing station 3's Maintenance Logbook (ML), was reviewed. LVN 3 stated if a call light was not working staff are to enter it into the ML. LVN 3 stated maintenance comes daily and checks the ML and signs off on all requests. LVN 3 reviewed the ML and stated there are no requests in the ML. During an interview on 12/7/23 at 2:58 p.m. with Maintenance Supervisor (MS), MS stated he had not received any other recent notification of issues with Resident 42's call light prior to 12/5/23. During an interview on 12/7/23 at 3:09 p.m. with Director of Nursing (DON), DON stated it is his expectation that if a call light is not working then the staff would supply the resident with a bell and notify maintenance. During an interview on 12/7/23 at 3:15 p.m. with Administrator, Administrator stated if a call light continues to come unplugged from the wall, then maintenance should have been called. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated October 2010, the P&P indicated, The purpose of this procedure is to respond to the residents requests and needs.6.Report all defective call lights to the nurse supervisor or maintenance promptly.

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

During a concurrent interview and record review on 12/6/23 at 3:34 p.m. with SSD, Resident 29's Advance Directive Acknowledgement (ADA), dated 8/6/2019, and ADA for Resident 78 dated 6/18/23 were revi...

Read full inspector narrative →

During a concurrent interview and record review on 12/6/23 at 3:34 p.m. with SSD, Resident 29's Advance Directive Acknowledgement (ADA), dated 8/6/2019, and ADA for Resident 78 dated 6/18/23 were reviewed. SSD confirmed there were no documented signatures on the ADA for Resident 79 and Resident 78. SSD stated, Yes the forms should have signatures. During a review of Resident 136's Facility Supplemental Documentation (Advanced Directive - [FSD-AD]), form dated 6/12/23, the FSD-AD form indicated, . 4. I am interested in executing an Advanced Directive (refer to SSD [social services director]). This was marked Yes by Resident 136's responsible party (RP). During a concurrent interview and record review, on 12/7/23 at 8:56 a.m. with SSD, Resident 136's Progress Notes (PN), were reviewed. SSD stated she was unable to find any follow up documentation of Resident 136's RP being contacted to provide information and assistance with creating an Advanced Directive. During a concurrent interview and record review on 12/6/23 at 3:33 p.m. with SSD, Resident 126's Consent to Treat(CTT), form dated 10/17/23 was reviewed. The CTT indicated, the ADVANCED DIRECTIVE ACKNOWLEDGEMENT portion of this document was not initialed by the resident or the resident representative. SSD stated this document was not initialed by Resident 126 or their resident representative. SSD stated it should have been initialed. During a concurrent interview and record review on 12/6/23 at 3:34 p.m. with SSD, Resident 11's CTT, form dated 12/7/22 was reviewed. The CTT indicated, the ADVANCED DIRECTIVE ACKNOWLEDGEMENT portion of this document was not initialed by the resident or the resident representative. SSD stated this document was not initialed by Resident 11 or their resident representative. SSD stated it should have been initialed. Based on interview and record review, the facility failed to ensure 9 of 66 sampled residents' (Resident 147, Resident 126, Resident 11, Resident 136, Resident 79, Resident 78, Resident 144, Resident 35, and Resident 61) information regarding Advanced Directives (AD - a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) was provided. This failure had the potential to result in Resident's being unable to make decisions about their medical care. Findings: During a concurrent interview and record review on 12/6/23 at 3:15 p.m. with Social Service Director (SSD), Resident 147's Facility Supplemental Documentation (Advanced Directive - [FSD-AD]), form dated 11/15/23 was reviewed. The FSD-AD form was blank with only the residents signature. SSD stated the form is blank and it should have been completed with the residents wishes. During a concurrent interview and record review on 12/6/23 at 3:39 p.m. with SSD, the Consent to Treat (CTT), forms of Resident 144 dated 7/3/23, Resident 35 dated 3/31/23, and Resident 61 dated 3/8/23 were reviewed. The CTT indicated the ADVANCED DIRECTIVE ACKNOWLEDGEMENT portion of this document were noted: Resident 144 - incomplete with no signature or initials, Resident 35 - incomplete with no signature or initials, Resident 61 - incomplete with no signature or initials. SSD confirmed the findings. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 2022, the P&P indicated, If the Resident does not have an Advance Directive 1. if the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff.Determining Existence of Advance Directive 5. If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the residents legal representative. If the Resident Does not have an Advance Directive 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. b. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to ensure six of six sampled Licensed Vocational Nurses (LVN 1, LVN 2, LVN 3, LVN 4, LVN 5 and LVN 6) had annual competency (measurable patter...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure six of six sampled Licensed Vocational Nurses (LVN 1, LVN 2, LVN 3, LVN 4, LVN 5 and LVN 6) had annual competency (measurable pattern of knowledge, skills and abilities an individual needs to perform occupational functions successfully) evaluations. This failure had the potential to result in nursing staff to not have specific skills and training needed to care for resident needs. Findings: During an interview on 12/6/23 at 8:54 a.m. with LVN 2, LVN 2 stated she is not sure how often competencies are checked. LVN 2 stated competency check are done randomly. During an interview on 12/6/23 at 9:17 a.m. with LVN 3, LVN 3 stated she does not remember when her last competency evaluation was performed. During an interview on 12/6/23 at 9:27 a.m. with LVN 4, LVN 4 stated she does not remember when her last competency evaluation was performed. During a concurrent interview and record review on 12/7/23 at 10:51 a.m. with Director of Staff Development (DSD), LVN 1's employee file (EF) was reviewed. DSD stated there were no competency evaluations in LVN 1's EF. DSD stated LVN 1 should have had a competency evaluation but it has not been done. During a concurrent interview and record review on 12/7/23 at 11:05 a.m. with DSD, LVN 2's EF was reviewed. LVN 2's EF indicated the most current competency evaluation was completed on 12/18/2010. DSD stated LVN 2 should have had an annual competency. DSD stated the Director of Nursing (DON) is responsible for evaluating the licensed staff competencies. During a concurrent interview and record review on 12/7/23 at 11:11 a.m. with DSD, LVN 3's EF was reviewed. LVN 3's EF indicated the most current competency evaluation was completed on orientation in 2015. DSD stated, Yes, LVN 3 should have had an annual competency evaluation. During a concurrent interview and record review on 12/7/23 at 11:16 a.m. with DSD, LVN 4's EF was reviewed. LVN 4's EF indicated the most current competency evaluation was completed on 9/28/21. DSD stated LVN 4 should have had an annual competency evaluation. During a concurrent interview and record review on 12/7/23 at 11:28 a.m. with DSD, LVN 5's EF was reviewed. LVN 5's EF indicated there were no competency evaluations performed upon hire or annually. DSD stated, Yes, she [LVN 5] should have had one [competency evaluation]. During a concurrent interview and record review on 12/7/23 at 11:32 a.m. with DSD, LVN 6's EF was reviewed. LVN 6's EF indicated there were no competency evaluations performed upon hire. DSD stated, Yes, LVN 6 should have had an orientation competency evaluation. During an interview on 12/7/23 at 12:10 p.m. with DON, DON stated competency evaluations is part of the orientation process. DON stated, I'm not gonna lie, we missed it. DON stated staff have not been getting competency evaluations. Staff competencies should be completed on hire and annually. During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, dated August 2021, the P&P indicated, Competent Staff.2. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirement defined by state law. 3. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) the following areas: a. Resident rights; b. Behavioral health; c. Psychosocial care; d. Dementia care; e. Person centered care; f. Communication; g. Basic nursing skills; h. Basic restorative services; i. Skin and wound care; j. Medication management; k. Pain management; l. Infection control; m. Identification of change in condition; and n. Cultural competency. 4. Licensed nurses and nursing assistants are trained and must demonstrate competency in identifying, documenting and reporting resident changes of condition consistent with their scope of practice and responsibilities. 5. Competency requirements and training for nursing staff are established and monitored by nursing leadership with input from the medical director to ensure that: a. programming for staff training results in nursing competency; b. gaps in education are identified and addressed; c. education topics and skills needed are determined based on resident population; tracking or other mechanisms are in place to evaluate the effectiveness of training; and e. training includes critical thinking skills and managing care in a complex environment with multiple interruptions.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to monitor, assess, document, and notify a change in condition for one of three sampled residents (Resident 1) when Resident 1 w...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to monitor, assess, document, and notify a change in condition for one of three sampled residents (Resident 1) when Resident 1 was left outside of the facility for a prolonged period of time. This failure resulted in Resident 1 feeling hot and had the potential for Resident 1 to experience heat stroke (body overheating). Findings: During an observation on 9/8/23 at 11:20 a.m. in Resident 1's room, Resident 1 was sitting in his wheelchair. Resident 1 was unable to be interviewed. During an interview on 9/8/23 at 11:20 a.m. with Family Member (FM) 1, FM 1 stated Resident 1 made his family aware staff left him outside and got too hot. FM 1 stated, My dad [Resident 1] told me the staff were checking him over and asking him how he was feeling [after being left outside for unknown period of time]. During a review of Resident 1's Minimum Data Set (MDS - assessment tool), dated July 17, 2023, the MDS indicated Resident 1 had a Brief Interview for Mental Status Score of 10 (score of 8-12 means moderately cognitively impaired). Resident 1's MDS indicated Resident 1 required extensive assistance with two or more persons physical assist with transfers and mobility. During an interview on 10/10/23 at 2:29 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she last saw Resident 1 at 11 a.m. ANA 1 stated, At 4 p.m. [five hours later] I looked outside, and he [Resident 1] was under the patio, by himself, he was very red, hot, and sweaty. He [Resident 1] felt hot, but I did not take his temperature. CNA 1 stated she reported the incident to Licensed Vocational Nurse (LVN) 1. During an interview on 10/10/23 at 3:40 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, No, I was never made aware of the incident [Resident 1 was found outside at the patio, feeling hot and sweaty]. LVN 1 stated she did not assess Resident 1, did not document the incident, and did not notify physician's order of the incident (Resident 1 being left outside and was feeling hot and sweaty). During a concurrent interview and record review on 10/10/23 at 4:00 p.m. with Administrator, Administrator reviewed Resident 1's clinical record and stated there was no documentation of Resident 1 had been left outside for an unknown amount of time or there being concerns from any staff about the Resident 1 becoming overheated. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated 2021, the P&P indicated, A significant change of condition is a major decline or improvement in the resident's status that: will not normally resolved itself without intervention by staff. The nurse will record in a resident's medical record information relative to changes in the residents medical/mental condition or status.

Oct 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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) wheelchair was free of debris. This resulted in Resident 1 using a dirty w...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) wheelchair was free of debris. This resulted in Resident 1 using a dirty wheelchair and the potential for spread of bacteria. Findings: During an observation on 8/21/23 at 11:09 a.m., in the outside patio, Resident 1 was observed sitting in [Resident 1's] wheelchair. The wheelchair had brown debris on the wheelchair seat, frame, and the wheels. During an interview on 8/21/23 at 11:17 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated the residents wheelchairs should be cleaned weekly. During a concurrent observation and interview on 8/21/23 at 11:28 a.m. with Licensed Vocational Nurse (LVN 1), in the outside patio, Resident 1's wheelchair was observed. LVN 1 stated, Resident 1's wheelchair was gross [it] looks like cornflakes stuck to it where the footrest go. During a concurrent observation and interview on 8/21/23 at 11:48 a.m. with Housekeeping Director (HD), in the outside patio, Resident 1's wheelchair was observed. HD stated Resident 1's wheelchair was dirty and appeared to have more than two weeks of dirt on it. HD stated The wheelchairs are on a monthly cleaning schedule and Resident 1's wheelchair should have been cleaned two weeks ago. HD stated the CNAs were responsible to take the residents wheelchairs to the housekeeper early in the morning to be cleaned. HD stated Resident 1's wheelchair should have been cleaned two weeks ago but was unable to provide evidence Resident 1's wheelchair was cleaned. During a review of the facility's policy and procedure (P&P), titled Cleaning and Disinfection of Resident-Care Items and Equipment dated 3/22, the P&P indicated, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected.

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

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed for one of three residents (Resident 1) refusal of care. This failure had the potential for ...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure a care plan was developed for one of three residents (Resident 1) refusal of care. This failure had the potential for staff to not know how to provide care to Resident 1 when refusing. Findings: During a review of Resident 1's Dental Notes (DN) dated, 8/11/23, the DN indicated, Tx [treatment] notes.Refused. During a review of Resident 1's Shower Day Skin Inspection (SDSI) sheets, dated 7/7/23, 7/11/23, 7/18/23, 8/15/23 and one undated indicated, Resident 1 had refused to shower. During an observation on 8/21/23 at 10:46 a.m. with Resident 1, in the outside patio, Resident 1 was observed sitting in [Resident 1's] wheelchair at a picnic table. Resident 1's fingernails were long and had brown debris under them. During an observation on 8/21/23 at 11:28 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 asked Resident 1 if she could clip [Resident 1]'s fingernails. Resident 1 refused to allow LVN 1 to clip [Resident 1]'s fingernails. During an interview on 8/21/23 at 11:35 a.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she had cared for Resident 1 in the past. CNA 2 stated Resident would refuse showers, and if staff member attempt to cut [Resident 1]'s fingernails, Resident 1 will ram into staff with [Resident 1]'s wheelchair and pinch staff. CNA 2 stated Resident 1 was difficult to provide care to. CNA 2 stated the day prior Resident 1 would not allow [Resident 1]'s family member to provide nail care. During an interview on 8/21/23 at 12:03 p.m. with CNA 3, CNA 3 stated Resident 1 was offered a shower in the morning and had refused. CNA 3 stated Resident 1 gets upset when she is offered a shower. During an interview on 9/8/23 at 10:31 a.m. with LVN 2, LVN 2 stated Resident 1 usually refuses showers. During a concurrent interview and record review on 8/22/23 at 1:14 p.m. with Director of Nursing (DON), Resident 1's Care Plans were reviewed. There was no care plan developed for Resident 1's refusal of care. DON stated Resident 1 refuses care and should have had a care plan developed. During a review of the facility's policy and procedure (P&P) titled Requesting, Refusing and/or Discontinuing Care or Treatment dated 2/2021, the P&P indicated, The IDT [Interdisciplinary Team-group of experts working together to treat your health condition] will assess the resident's needs and offer the resident/representative alternative treatments, if available and pertinent, while continuing to provide other services outlined in the care plan.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the Podiatrist (doctor that treats the feet) recommendation for a pressure ulcer (injury to skin and underlying tissue...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure the Podiatrist (doctor that treats the feet) recommendation for a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin) was followed upon for one of three sampled residents (Resident 1). This failure resulted in a delay in care for Resident 1 and the potential for Resident 1 to experience worsening of the pressure ulcer. Findings: During a review of the Podiatry Evaluation (PE), dated 8/19/23, the PE indicated, Treatment.Pressure ulcer, ankle, left, unstageable (pressure ulcer when a stage is not clear).Notes: The wound appears stable and should heal with local care. Plan of care should be daily betadine application and offloading with pillows. During a concurrent interview and record review on 9/8/23 at 10:31 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 reviewed Resident 1's clinical record and was unable to find any treatment or monitoring to Resident 1's pressure ulcer. During an observation on 9/8/23 at 11:10 a.m. with LVN 2, in Resident 1's room, there was a scab on Resident 1's left ankle. LVN 2 stated there was no ongoing treatment or monitoring to the scabbed area. During a concurrent interview and record review on 9/8/23 at 11:19 a.m. with Treatment Nurse (TN), TN stated she was made aware of the pressure ulcer by Resident 1's nurse. TN stated when she went to look at the pressure ulcer, the pressure ulcer was above the outside ankle bone on the left foot. TN stated while she was assessing the pressure ulcer Resident 1 swatted the scab off herself and there was nothing under the scab. TN stated she notified the Physician and there were no new orders for the pressure ulcer. TN was unable to provide any documentation the pressure ulcer was followed upon or the Physician was notified. TN stated when the pressure ulcer was identified and the physician was notified it should have been documented in Resident 1's clinical record. During an interview on 10/2/23 at 2:30 p.m. with Director of Nursing (DON), DON stated when TN followed up on the pressure ulcer with the physician it should have been documented. During a review of the facility's policy and procedure (P&P) titled Foot Care dated 10/22, the P&P indicated, Residents are provided with foot care and treatment in accordance with professional standards of practice.Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions.

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) call light was functioning properly when the call light box was manipulated with a push ...

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) call light was functioning properly when the call light box was manipulated with a push pin preventing it from working. This failure resulted in Resident 1 being unable to call for assistance. Findings: During an interview on 5/12/23, at 10:11 a.m., with Resident 1, Resident 1 stated, I use my call light to call staff when I need assistance or a pain pill, because I had my leg amputated. Resident 1 stated, when I was calling for help no one was coming and I was not very happy about it, but what could I do? Resident 1 stated, How would anyone feel if they couldn ' t call for help? During an interview, on 5/12/23, at 10:16 a.m., with Staff 1, Staff 1 stated, approximately two weeks ago when [Staff 1] came on shift at 6 a.m., [Resident 1] ' s call light box contained a push pin in place of the button used to shut off the call light. Staff 1 stated, when the push pin was in the call light box and Resident 1 pushed the call light for assistance, the push pin prevented the call light from lighting up and alerting the staff. During an interview on 5/12/23, at 12:11 p.m., with Director of Staff Development (DSD), DSD stated, a Certified Nursing Assistant (CNA), reported to her approximately three weeks ago, there was a push pin in Resident 1 ' s call light box. DSD stated, when she checked Resident 1 ' s call light box, there was a push pin that she removed. DSD stated, after the push pin was removed the call light was functioning properly. DSD stated, the call light was the life line for the resident and should not have been manipulated. During an interview on 5/12/23, at 12:31 p.m., with Maintenance Director (MD), MD stated, a few weeks ago, the morning staff, made him aware of a push pin in Resident 1 ' s call light box. MD stated, when he checked Resident 1 ' s call light box, the cap, used to turn the light off, was missing from the call light box and a yellow push pin was where the cap was supposed to be. MD stated, when the push pin was in the call light box, the call light was not working. MD stated, the call light should not have been manipulated because it prevented Resident 1 from communicating the need for assistance. During an interview on 5/12/23, at 12:37 p.m., with Administrator, Administrator stated, on 4/21/23, a CNA reported there was a push pin in Resident 1 ' s call light receptacle that prohibited the call light from working when the button was pushed. During an interview on 5/24/23, at 4:53 a.m., with CNA 1, CNA 1 stated, on 3/30/23, at 9:19 p.m., she was in Resident 1 ' s room and seen a black push pin in the call light box for Resident 1. CNA 1 stated, she took a picture and reported it to the Assistant Director of Nursing. CNA 1 stated, when Resident 1 pushed the call light button it would not turn on because the push pin was holding down the button that turned off the call light preventing it from functioning. During a review of the facility's policy and procedure (P&P) titled, Nurse Call Light System Testing, undated, the P&P indicated, b. Check each residents room to ensure it activates light over entry door and at nurses station. c. Insure that the wall receptacle is not cracked, broken or damaged in any manner. d. Ensure that the call light cord fastening device that hooks the cord to the bed is usable.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to follow its abuse policy and procedure (P&P) for one of four sampled residents (Resident 1), when the facility failed to report an allegatio...

Read full inspector narrative →

Based on interview and record review, the facility failed to follow its abuse policy and procedure (P&P) for one of four sampled residents (Resident 1), when the facility failed to report an allegation of physical abuse in a timely manner. This failure had the potential for further abuse and psychosocial distress to Resident 1. Findings: During a review of Resident 1's Progress Notes (PN), dated 4/8/23 at 4:16 PM, the PN indicated, Resident [1] is currently up in her w/c [wheelchair] on hallway. Approached this CN [Charge Nurse] and stated, She hit me! when asked who hit her, [Resident 1] stated, My daughter hit me in my face. She hit my sore leg and she just did it on purpose!. During an interview on 4/12/22, at 9:41 AM, with Social Services Director (SSD), SSD stated Licensed Vocational Nurse (LVN) had written a Progress Notes (PN) on 4/8/23, regarding an alleged physical abuse. SSD stated the allegation was not reported to the proper authorities including the State Agency (California Department of Public Health), law enforcement, Ombudsman (patient advocate) until 4/10/23, two days after the allegation of physical abuse was made. During an interview on 4/12/23, at 10:23 AM, with Licensed Vocational Nurse (LVN-also known as CN), LVN stated on 4/8/23, she was in the hallway when she heard Resident 1 say she hit me. LVN 1 stated upon further questioning Resident 1 of the allegation, Resident 1 had stated she was hit by her daughter. LVN stated at the end of her shift on 4/8/23, she had notified the Assistant Director of Nurses (ADON) of the alleged physical abuse made by Resident 1. During an interview on 4/12/23, at 11:11 AM, with Director of Nurses (DON), DON stated it was the facility policy for staff to immediately report any accusation of abuse to the DON and SSD. During an interview on 4/14/23, at 10:43 AM, with ADON, ADON stated on 4/8/23, she remembered LVN reported to her an allegation of physical abuse made by Resident 1. ADON stated she had intended to report the allegation but had forgotten. ADON stated the alleged physical abuse was not reported to the proper authorities until 4/10/23, two days after she was made aware of the allegation of physical abuse. ADON stated the alleged physical abuse should have been reported to the proper authorities immediately. During a review of Resident 1's Minimum Data Set (MDS-a standardized, comprehensive assessment tool), dated 2/19/23, the MDS indicated, Resident 1 had a BIMS [Brief Interview for Mental Status-which evaluates cognition, the ability to remember and think clearly] score of 2 (score of 0-7 severe impairment). During a review of the facility's P&P titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating dated 9/22, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. 1. If resident abuse, neglect, exploitation, misappropriation of property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 3. Immediately is defined as: as within two hours of an allegation involving abuse.

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from sexu...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from sexual abuse. This failure had the potential for negative physical and psychosocial outcomes for Resident 1. Findings: During an interview on 3/2/23, at 10 AM, with Social Services Director (SSD), SSD stated on 2/28/23, Resident 1 verbalized Resident 2 pinched her breast on 2/27/23. SSD stated, Resident 1 informed SSD she and Resident 2 will get married, but she did not give him (Resident 2) permission to touch her breast. SSD stated, Resident 1 told Resident 2 to stop touching her breast and he (Resident 2) did. During an interview on 3/2/23, at 10:20 AM, with Resident 1, Resident 1 stated, He [Resident 2] got a little bit too fresh. Resident 1 stated, Resident 2 pinched her breast, she told him to stop, and he did. During an interview on 3/2/23, at 10:38 AM, with Resident 2, Resident 2 stated, She [Resident 1] told me I could touch her breast, I touched her breast over her shirt. During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment tool to determine resident's needs) dated 2/7/23, the MDS indicated, Resident 1 had a BIMS (Brief Interview for Mental status-questions used to determine mental status) score of 7 (indicating severe mental impairment). During a review of Resident 1's admission Record, dated 2/2/23, the admission Record indicated, Resident 1 had a diagnosis of Schizophrenia (A disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2 had a BIMS score of 10 (indicating moderate mental impairment). During a review of Resident 2's Interdisciplinary team (IDT-group of multiple staff) meeting note dated 2/28/23, IDT note indicated, [Resident 2] did verbalize he barely touched her [Resident 1] on her upper chest area with her consenting. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program , dated April 2021, the P&P indicated, Residents have the right to be free from abuse .This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse.

Dec 2021 21 deficiencies

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to notify physician for a worsening condition for one of 82 sampled residents (Resident 71). This failure resulted in an infecti...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to notify physician for a worsening condition for one of 82 sampled residents (Resident 71). This failure resulted in an infection and pain for Resident 71. Findings: During a concurrent observation and interview on 12/6/21, at 11:15 AM, with Resident 71, in Resident 71's room, both of Resident 71's legs and feet were observed to be red, swollen, blistered, and peeling. Resident 71 stated, The bottom of my legs peel. Staff is aware and doesn't do anything. They [staff] tell me to put Vaseline on it. During a concurrent observation and interview on 12/7/21, at 9:30 AM, with Resident 71, outside of her room, Resident 71 was sitting in her walker with soft slippers on. Resident 71's ankles observed to be bright red and peeling. When she took off her slippers, significant edema was observed. Resident 71 stated, staff does nothing about it and she wished they would do something. During a concurrent interview and record review, on 12/8/21, at 2:44 PM, with Licensed Vocational Nurse (LVN) 7, Resident 71's medical record was reviewed. LVN 7 stated, she was not aware there was an issue with Resident 71's feet and legs. LVN 7 stated, there was no active treatment orders or documentation of the physician being notified of her change of condition. During a concurrent observation and interview on 12/8/21, at 3:04 PM, with Nurse Consultant (NC), in Resident 71's room, NC observed Resident 71's feet and legs. NC stated, Physician should have been notified of her worsening skin condition. During a review of Resident 71's Change of condition - Edema of new onset (COC), dated 11/22/21, the COC indicated, Description: +3 pitting edema [swelling] b/l [bilateral-both] ankles. Resident noted with pitting edema to bilateral ankles, skin is warm. redness noted to bilateral lower legs. 11/25/21 12:27 PM Resident is on monitoring for bilateral ankle edema. No warmth to ankles noted. It was noted there was no documentation monitoring of bilateral edema was done after 11/25/21. During an interview on 12/8/21, at 4:06 PM, with Director of Nursing (DON), DON stated, there was an event created in November 2021 regarding Resident 71's ankle edema. DON stated, the last thing charted was on November 25th. DON stated, the physician should have been notified of the worsening condition. During a review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated December 2016, the P&P indicated, Our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and/or status. 1. The nurse will notify the resident's Attending Physician when there has been a(an): h. specific instruction to notify the Physician of changes in the resident's condition.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop individualized care plans for two of 82 sampl...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop individualized care plans for two of 82 sampled residents (Resident 25 and Resident 129) when: 1. There was no care plan for refusal of care for Resident 25. This failure had the potential for Resident 25's needs not attended to and potential to result in decline in healthcare condition. 2. There was no care plan for activities for Resident 129. This failure had the potential for Resident 129 not provided with appropriate activities, affecting his psychosocial needs. Findings: 1. During an observation on 12/6/21, at 10 AM, in Resident 25's room, Resident 25 was lying in her bed staring at the ceiling. Resident 25 was confused and unable to answer questions. During an observation on 12/7/21, at 9:05 AM (the next day), in Resident 25's room, Resident 25 was awake, lying in bed talking to no one. During an interview on 12/7/21, at 10:02 AM, with Nursing Assistant (NA 2), NA 2 stated Resident 25 refused to get up on a wheelchair. They do not get Resident 25 up. NA 2 stated, The nurses are aware resident [25] was refusing to get up. During a concurrent interview and record review on 12/7/21, at 10:35 AM, with Licensed Vocational Nurse (LVN) 10, Resident 25's Care Plan (CP), dated 9/21/21 was reviewed. LVN 10 stated, There's no care plan for refusal of care. During a review of the facility's policy and procedure (P&P) titled, Refusal of Treatment/Care, undated, the P&P indicated, The interdisciplinary team will assess the resident's needs and offer the resident alternative treatments, is available and pertinent, while continuing to provide other services outlined in the care plan. 2. During an observation on 12/6/21, at 10:20 AM, in the hallway, Resident 129 was walking and wandering back and forth the hallway. No activity was offered and staff kept redirecting him. During an interview on 12/6/21, at 10:22 AM, with NA 2, NA 2 stated, he had not seen activities' personnel come in and offer him (Resident 129) anything to do. During a concurrent interview and record review on 12/8/21, at 12:43 PM, with Activity Director (AD), Resident 129's Face Sheet (FS), dated 11/19/21 was reviewed. The FS indicated, Resident 129 was admitted on [DATE] (19 days ago). AD stated, Resident 129 had no documented care plan for activities. AD stated, she is new to her position and was unable to catch up with documentation. During a review of the facility's policy and procedure (P&P) titled, Care Planning - Interdisciplinary team, undated, the P&P indicated, Our facility's Care planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Based on observation, interview, and, record review, the facility failed to revise and update one of 82 sampled residents (Resident 25) care plan. This failure had the potential for Resident 25 not re...

Read full inspector narrative →

Based on observation, interview, and, record review, the facility failed to revise and update one of 82 sampled residents (Resident 25) care plan. This failure had the potential for Resident 25 not receiving the appropriate care according to current health status. Findings: During an observation on 12/6/21, at 10 AM, in Resident 25's room, Resident 25 was lying in bed awake, staring at the ceiling, and talking to herself. During a review of Resident 25's Care Plan (CP), dated 12/7/21, CP indicated, [Resident 25] enjoys spending most of her day about the facility, listening to classical music. Resident also loves to dance. Resident loves to be around animals such as dogs and cats. Resident enjoys keeping house clean, and checking out men, resident also loves poetry. During an interview on 12/7/21, at 12:03 PM, with Nursing Assistant (NA) 2, NA 2 stated, Resident 25 does not do those activities anymore. NA 2 stated, They should revise the care plan according to the resident's current status. During a review of Resident 25's Activity Attendance Sheet (AAS), dated 11/2/21 until 12/6/21, AAS indicated, Resident 25 was not provided or offered activities according to the care plan. During a concurrent interview and record review on 12/8/21, at 12:43 PM, with Activity Director (AD), AD stated, she is new to her position and was unable to catch up with documentations and had not updated and revised activities' care plans. During a review of the facility's policy and procedure (P&P) titled, Care Plan-Comprehensive, dated 1/11, P&P indicated, 8. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.

CONCERN (D)

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

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 82 sampled residents (Resident 102) rec...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 82 sampled residents (Resident 102) received proper treatment and care for Resident 102's toenails and feet. This failure resulted in Resident 102 having pain, and thick, distorted, discolored, and infected toenails. Findings: During a concurrent observation and interview on 12/7/21, at 11:23 PM, with Resident 102, in Resident's 102's room, Resident 102's feet were observed to be red, swollen, blistered with long toenails that curved above his toes. Resident 102 stated, his nails have not been clipped since he was admitted and stated he would like his nails clipped. During a concurrent observation and interview on 12/8/21, at 12:29 PM, with Licensed Vocational Nurse (LVN) 6, in Resident 102's room, LVN 6 observed Resident 102's feet and stated, Resident 102 needed a podiatry (Foot Doctor) visit, his toenails are long and beyond needing a trim. LVN 6 stated, his medical chart does not indicate he has a podiatry appointment set up. During an interview on 12/8/21, at 2:45 PM, with Social Services Director (SSD), SSD stated, Resident 102 has not been seen by Podiatry since his admission. SSD stated, Podiatry came the 1st of December (2021) to the facility. During a review of Resident 102's Admissions Record (AR), dated 11/5/21, the AR indicated, Resident 102 was admitted on [DATE], and had admission diagnosis of Quadriplegia (Paralysis of all four limbs) and Diabetes Mellitus (high blood sugar) with Diabetic Neuropathy (nerve damage to the legs and feet). The AR indicated, resident's preferred language was English and could verbalize his needs. During a review of Resident 102's Physician Orders (PO), dated 11/5/21, the PO indicated, Consult-Podiatry As Needed for Mycotic [infection that effects the toe nails]/Hypertrophic [thick] Nails And/Or Keratotic [over growth] Lesions. During a review of the facility's policy and procedure (P&P) titled, Foot Care, dated March 2018, the P&P indicated, Residents will receive appropriate care and treatment in order to maintain mobility and foot health. 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care will include the care and treatment of medical conditions associated with foot complications (e.g., diabetes. ).

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure an effective systematic approach to optimize one of 82 sampled resident's (Resident 20's) nutritional status when: 1. ...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure an effective systematic approach to optimize one of 82 sampled resident's (Resident 20's) nutritional status when: 1. The facility failed to implement a physician's order for a health shake (used to increase intake of calories and protein). 2. The facility failed to ensure the weight goal range was established with the involvement of the resident and/or resident's legal representative, and in accordance with standards of practice. These failures had the potential to negatively compromise the resident's nutrition and medical status. Findings: 1. During an observation on 12/6/21, at 12:41 PM, Resident 20 received his lunch meal tray in his room. The beverages on Resident 20's meal tray were four ounces (oz.) of milk and 8 oz. of water, which was in accordance with the directions on the meal tray ticket. There was not a health shake on Resident 20's meal tray. During a concurrent observation and interview on 12/7/21, at 12:32 PM, with Registered Dietitian (RD) 1, RD 1 removed Resident 20's lunch meal tray from the meal delivery cart. RD 1 acknowledged the meal tray ticket did not indicate to provide a health shake, and there was not a health shake on the tray. During a concurrent interview and record review, on 12/7/21, at 12:32 PM, RD 1 reviewed Resident 20's physician orders and verified there was a current order to provide 4 (four) oz. (ounce) shakes TID (three times a day) with meals. RD 1 stated the order must not have been communicated to the kitchen. During an observation on 12/7/21, at 12:36 PM, Resident 20's lunch meal tray was observed without a health shake provided. Resident 20's meal tray ticket did not contain directions to the kitchen staff to provide health shakes with meals. During a review of Resident 20's PO (physician orders), dated 6/15/21, the PO indicated, Give 4 oz shakes TID with meals, Special Instructions: . Supplement Three Times A Day; 07:00 [7 AM], 12:00 [12 PM], 18:00 [6 PM]. During a review of Resident 20's Resident Progress Notes for RD/IDT Weight Meeting (RPNWM), the following was noted: RPNWM, dated 5/13/21; Wt [weight]: 159 lbs [pounds] RPNWM, dated 5/27/21; Wt: 149 lbs RPNWM, dated 6/3/21; Wt: 147 lbs RPNWN, dated 6/10/21; Wt: 145 lbs RPNWN, dated 6/24/21; Wt: 143 lbs RPNWN, dated 7/7/21; Wt: 148 lbs Resident 20 lost 11 lbs from 5/13/21 to 7/7/21. During a concurrent interview and record review on 12/8/21, at 10:14 AM, with RD 1, Resident 20's Resident Progress Notes RD/IDT Weight Meeting (RPNWM), dated 7/7/21, was reviewed. RPNWM indicated, Wt: 148 lbs .Supplements: FeSO4 [iron], 60 ml [milliliters] MedPass 2.0 [nutrition drink to increase calories and protein] BID [two times a day] (5/13/21); 4 oz Shakes TID w/ [with] meals (6/15/21) ., Prior interventions: Shakes w/meals, Remeron [medication for depression] for poor p.o. [food by mouth] intake, ST [speech therapist] eval [evaluation] .MedPass, obtain food preferences . RD 1 stated the documentation of the IDT meeting into Resident 20's electronic medical record was completed by her. During a concurrent interview and record review on 12/8/21, at 10:14 AM., RD 1 reviewed the order to give 4 oz shakes TID with meals, dated 6/15/21. RD 1 stated the shakes would have come from the kitchen on the meal tray. RD 1 stated the 4 oz. shakes TID with meals had never been provided to Resident 20 since ordered, six months earlier, as the kitchen did not know about it. During a review of the facility's policy and procedure (P&P) titled, Tray Card System, approved by the facility on 2/16/21, the P&P indicated, Policy: Each meal tray at breakfast, lunch and dinner will have a tray card which designates the resident's name, diet, food dislikes, food requests, allergies, beverage preference and portion size. 2. During a concurrent interview and record review on 12/8/21 at 10:14 AM., with RD 1, Resident 20's IDT Nutrition Care Plan (NCP), with an approach start date of 3/14/21, and last reviewed/revised 9/13/21 was reviewed. The NCP indicated, Weight goal range: 165 +/- [plus or minus] 5 lbs. During a concurrent interview and record review on 12/8/21, at 10:14 AM, with RD 1, Resident 20's IDT NCP, last reviewed/revised 12/6/21, indicated, Weight goal range: 154 - 188 lbs; Approach start date: 3/28/2021. RD 1 stated she determined the weight goal range for Resident 20 based on a chart titled, Average Weight of Americans Aged 65-94 for Men, dated 1960 from the American Medical Association. RD 1 stated she had not involved the resident and/or the resident's representative, nor the physician, in establishing the weight goal range to ensure it was individualized and met their personal goals and preferences. RD 1 verified the weight goal range was not individualized for the resident, as it was based on her routine methodology to use the chart grid, independent of the resident's usual body weight or nutritional status. RD 1 verified Resident 20 weighed 168 pounds on 3/7/21. RD 1 calculated the percent weight difference between 168 pounds to 154 pounds (the lower end of the weight goal range she communicated to the IDT team as being acceptable) and stated that would be an 8% loss in body weight. RD 1 stated Resident 20 was not on a physician prescribed weight loss program. RD 1 stated the facility would be concerned if a resident lost 2% of body weight in one week, 5% in one month, 7.5% in three months, and 10% in six months. RD 1 stated she used the chart to document the weight goal range but then she never looked at it again. RD 1 acknowledged that it had potential to communicate to the IDT that a weight loss would be acceptable if it was within the documented range. RD 1 acknowledged that she had not implemented geriatric nutrition standards of practice when determining a weight goal range on the IDT Nutrition Care Plan, and confirmed weight loss was not the goal for Resident 20. During a review of the facility's policy and procedure (P&P) titled, Care Planning - Interdisciplinary Team, dated 1/11, the P&P indicated, Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated 9/08, the P&P indicated, Policy Statement: The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents ., Care Planning; 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or residents legal surrogate . During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated 10/17, the P&P indicated, The nutritional assessment will be conducted by the multidisciplinary team and shall identify at least the following components: . (1) Usual body weight; (2) Current height and weight ., Sources of information for the resident nutritional assessment may include the following: .e. Resident and family interview., .individual care plans will be developed that address or minimize to the extent possible the resident's risks for nutritional complications. Such interventions will be developed within the context of the resident's prognosis and personal preferences. Individualized care plans shall address, to the extent possible: a. The identified causes of impaired nutrition; b. The resident's personal preferences; c. Goals and benchmarks for improvement; and d. Time frames and parameters for monitoring and reassessment. According to American Family Physician, 2/152002/Volume 65, Number 4, Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. According to www.aafp.org/afp American Family Physician (2/15/2002/Volume 65, Number 4), Involuntary weight loss can lead to muscle wasting, decreased immunocompetence (the ability of the body to produce a normal immune response following exposure to a virus, bacteria, or spore, etc.), depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity (illness) and mortality (death). One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to monitor for behaviors associated with the use of one psychotropic medication for one of 82 sampled residents (Resident 127). This failure r...

Read full inspector narrative →

Based on interview and record review, the facility failed to monitor for behaviors associated with the use of one psychotropic medication for one of 82 sampled residents (Resident 127). This failure resulted in facility being unable to monitor the effectiveness of Resident 127's psychotropic medication. Findings: During a concurrent interview and record review, on 12/9/21, at 9:32 AM, with Licensed Vocational Nurse (LVN) 8, Resident 127's Medication Administration Record (MAR) dated 12/21 was reviewed. The MAR indicated that from 12/1/21 through 12/8/21, he received the medication divalproex for schizophrenia, a serious mental disorder in which people interpret reality abnormally and may result in some combination of hallucinations, delusions, and extremely disordered thinking and behavior that impairs daily functioning. The MAR indicated Resident 127 was not monitored for any of these (or any) potential behaviors commonly associated with schizophrenia. LVN 8 confirmed the finding and stated, This needs to be corrected. During a review of the facility's policy and procedure (P&P) titled, Psychotropic Medication Use, dated 3/18, the P&P indicated, Monitoring of a resident receiving Psychotropic medication will include evaluation of the effectiveness of the medication. Behavioral symptoms are reevaluated periodically to determine the potential for reducing or discontinuing the drug based on therapeutic goals.

CONCERN (D)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure a cook was competent to follow a fortified diet order for one of 82 sampled residents (Resident 69). This failure had ...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure a cook was competent to follow a fortified diet order for one of 82 sampled residents (Resident 69). This failure had the potential for Resident 69's nutritional needs to have been unmet. Findings: During a concurrent observation and interview on 12/7/21, at 12:10 PM, during lunch trayline in the kitchen, [NAME] 1 was observed placing food onto Resident 69's lunch meal plate. [NAME] 1 handed the lunch meal plate to a dietary aid for the cold foods to be placed onto the meal tray. [NAME] 1 was asked what the fortified item was for Resident 69. [NAME] 1 reviewed Resident 69's lunch meal plate and stated that he should have served one tablespoon (TBSP) of butter over the pasta as the fortified food item for lunch. [NAME] 1 asked the dietary aid to hand Resident 69's plate back to him so he could serve the fortified food item in accordance with the diet order, listed on the meal tray card. During a review of Resident 69's meal tray card, the meal tray card indicated, Puree/fortified. During a review of Resident 69's PO (physician orders), dated 4/24/20, the diet order indicated, Diet: Fortified, Puree. During a review of the facility's policy and procedure (P&P) titled, Fortification of Food: Increasing Calories And/Or Protein In The Diet, approved by the facility on 2/16/21, the P&P indicated, Policy: The enrichment of foods will be done on an individual basis for the residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. Purpose: The goal is to increase the calorie and/or protein density of the foods commonly consumed by the resident to promote improvement in their nutritional status ., Residents considered will have demonstrated an inability to consume the amounts of foods required to prevent significant weight loss, skin breakdown, and/or visceral protein loss ., Adding Calories - ½ oz (ounce) melted margarine [equivalent to 1 TBSP of butter] will be added to 1-2 food items per meal . adds 100 calories per ½ oz . During a review of the facility's policy and procedure (P&P) titled, Tray Card System, approved by the facility on 2/16/21, the P&P indicated, Policy: Each meal tray at breakfast, lunch and dinner will have a tray card which designates the resident's name, diet, food dislikes, food requests, allergies, beverage preference and portion size.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to follow the menu for a CCHO (controlled carbohydrate/diabetic diet) diet for one of 82 sampled residents (Resident 20) when ge...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to follow the menu for a CCHO (controlled carbohydrate/diabetic diet) diet for one of 82 sampled residents (Resident 20) when gelatin was served, instead of diet gelatin as planned. This failure had the potential to not meet the resident's nutritional needs per the planned menu as approved by the facility's Registered Dietitian. Findings: During a concurrent observation and interview, on 12/7/21, at 12:18 PM, during lunch trayline in the kitchen, Dietary Aide (DA) 1 placed Resident 20's lunch meal tray onto the meal delivery cart. DA 1 was asked to remove Resident 20's lunch meal tray and review it for accuracy. DA 1 stated regular gelatin was placed on the tray, but it should have been diet gelatin for the CCHO diet. During a review of Resident 20's meal tray card, the meal tray card indicated, Mech. [mechanical] soft/Puree Meat, Renal [diet for kidney disease], CCHO [diet for diabetes]. During a review of the planned menu for CCHO diet, 1/2 c [cup] Diet Gelatin. During a review of Resident 20's PO (physician orders), dated 5/25/21, the PO indicated, Mechanical soft diet, with puree meat; CCHO; renal. During an interview on 12/8/21, at 4:45 PM, with RD 1, RD 1 verified the finding. During a review of the facility's policy and procedure (P&P) titled, Menu Planning, dated 2/16/21, the P&P indicated, The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are to be approved by the facility Registered Dietitian prior to the beginning of each quarterly menu cycle. During a review of the facility's policy and procedure (P&P) titled, Tray Card System, dated 2/16/21, the P&P indicated, Policy: Each meal tray at breakfast, lunch and dinner will have a tray card which designates the resident's name, diet, food dislikes, food requests, allergies, beverage preference and portion size.

CONCERN (E)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement baseline care plans for 8 of 82...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement baseline care plans for 8 of 82 sampled residents (Resident 85, Resident 102, Resident 123, Resident 528, Resident 530, Resident 531, Resident 533, and Resident 535). This failure had the potential for these residents not receiving the necessary care and services needed for their health and safety. Findings: During a concurrent observation and interview on 12/7/21, at 2:12 PM, with Resident 85, in Resident 85's room, resident was observed not participating in any activities or had activities provided to her this day. Resident 85 stated, she has not done any activities today and stated, I like to knit. During a concurrent observation and interview on 12/8/21, at 4 PM (the next day), with Resident 85, in Resident 85's room, resident had not participated in any activity or had activities provided to her this day. Resident 85 stated, Activities has not brought anything for me to do today. During a review of Resident 85's Resident Face Sheet (RFS), dated 11/11/21, the RFS indicated, Resident 85 is an [AGE] year-old female who was admitted on [DATE]. During an interview on 12/8/21, at 9:16 AM, with Resident 123, Resident 123 stated, no activity staff have come to her room to discuss what kind of activities she likes or offer to take her to do any group activities. During a review of Resident 123's RFS, dated 11/11/21, the RFS indicated, Resident 123 is a [AGE] year-old female who was admitted on [DATE]. During a concurrent interview and record review, on 12/8/21, at 4:27 PM, with Director of Nursing (DON), Resident 85, Resident 102, and Resident 123's baseline care plans for activities were reviewed. The baseline care plans indicated, there was not one developed or implemented for Activities. DON stated, an Activity baseline care plan was not done for Resident 85, Resident 102, and Resident 123 and one should have been created. During a review of Resident 102's RFS, dated 11/5/21, the RFS indicated, Resident 102 is a [AGE] year-old male who was admitted on [DATE]. During an interview on 12/9/21, at 9:07 AM, with Resident 102, Resident 102 stated, there has not been any activity staff come to his room to discuss what kind of activities he likes or offer to take him to do any group activities. During an interview on 12/9/21, at 10:29 AM, with Administrator, Administrator stated, the new activities director started on 10/28/21 and is not caught up on the new admissions and has not created or implemented baseline care plans for Resident 85, Resident 102, and Resident 123. During an interview on 12/6/21, at 10:01 AM, with Resident 528, Resident 528 stated, No, I have not seen the activities girl. Resident 528 stated, activities had not visited the resident. During a review of Resident 528's RFS, dated 12/2/21, the RFS indicated, Resident 528 is a [AGE] year-old male who was admitted on [DATE]. During an interview on 12/7/21, at 12:06 PM, with Resident 530, Resident 530 stated, she watches television. Resident 530 stated, no one from activities has come into her room. During a review of Resident 530's RFS dated 11/15/21, the RFS indicated, Resident 530 is a [AGE] year-old female who was admitted on [DATE]. During a review of Resident 531's RFS dated 11/24/21, the RFS indicated, Resident 531 is a [AGE] year-old male who was admitted on [DATE]. During a review of Resident 533's RFS dated 11/22/21, the RFS indicated, Resident 533 is a [AGE] year-old male who was admitted on [DATE]. During a review of Resident 535's RFS dated 11/15/21, the RFS indicated, Resident 535 is a [AGE] year-old female who was admitted on [DATE]. During a concurrent interview and record review on 12/8/21, at 12:43 PM, with Activity Director (AD), AD stated, she is new to her position and was unable to catch up with documentation's and had not updated and revised or developed baseline activities' care plans. During a concurrent interview and record review on 12/8/21, at 4:08 PM, with Activity Director (AD), AD reviewed the Activity section in electronic medical records for the resident's (Resident 538, Resident 530, Resident 531, Resident 533, Resident 535). The AD stated, These are new admits, I have not seen them. I have not done any baseline activity care plans. The facility policy and procedure had been requested on baseline care plan, none were provided.

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure an initial nutritional assessment was comp...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure an initial nutritional assessment was completed for Resident 129. This failure had the potential for Resident 129's nutritional needs not being met. 2. Ensure the quarterly nutritional assessments were completed for Resident 17, Resident 25, and Resident 111. This failure had the potential for these residents' nutritional status not being monitored. Findings: 1. During a review of Resident 129's clinical records, there was no initial nutritional assessment. Resident 129's Physician Order Report, dated 11/19/21, indicated, Resident 129 was admitted to the facility on [DATE] (16 days ago). During a concurrent interview and record review on 12/8/21, at 10:45 AM, with Director of Nursing (DON), Resident 129 nutritional assessment was reviewed and he stated, There is no initial nutritional assessment completed for resident [129]. 2. During an observation and interview on 12/6/21, at 11:57 AM, with Resident 17, in the patio, Resident 17 was drinking an iced coffee and eating food from outside of the facility. Resident 17 stated, he buys food from the outside due to not being happy with the food the facility serves. During a review of Resident 17's RDN [Registered Dietician Notes] Nutritional Observation (RDNNO), dated 6/16/21, the RDNNO was last completed on 6/16/21 (over five months ago). During a review of Resident 25's RDNNO, dated 1/19/21, the RDNNO was last completed on 1/19/21 (over 10 months ago). During a concurrent interview and record review on 12/8/21, at 10:45 AM, with DON, DON reviewed the clinical records of Resident 17 and Resident 25 and he stated, I can't find the latest quarterly nutritional assessment for these residents. RD [Registered Dietitian] did not tell us she was behind. During an interview on 12/8/21, at 11:35 AM, with RD, RD stated she thought she could catch up with documentation, but she was unable to. RD stated, she did not let management know she was behind on her assessments. RD verified the finding. During a review of the facility's policy and procedure (P&P) titled, Nutritional Assessment, dated 10/17, P&P indicated, As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. 1. The dietitian, in conjunction with nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframe's) and as indicated by a change in condition that places the resident at risk for impaired nutrition.

CONCERN (E)

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure seven of 82 sampled residents (Resident 25, Re...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure seven of 82 sampled residents (Resident 25, Resident 57, Resident 64, Resident 102, Resident 103, Resident 111, and Resident 330) received assistance with Activities of Daily Living (ADLs - hygiene, elimination, dining, and communication). This failure had the potential for residents' decline in healthcare conditions and unmet hygiene and grooming needs. Findings: 1. During an observation on 12/6/21, at 10 AM, in Resident 25's room, Resident 25 was lying in her bed staring up at the ceiling. Resident 25 seemed confused and unable to answer questions. During an observation on 12/7/21, at 9:05 AM (the next day), in Resident 25's room, Resident 25 was awake, lying in bed talking to no one. During a review of Resident 25's MDS (MDS-comprehensive assessment tool), dated 9/21/21, the MDS indicated, Resident 25 required total assistance with two persons physical assist with transfers. During an interview on 12/7/21, at 10:02 AM, with Nursing Assistant (NA) 2, NA 2 stated, they do not get Resident 25 up. During an interview on 12/7/21, at 11:10 AM, with NA 2, NA 2 stated, We are short staffed, we have 15 residents each and we are unable to give the adequate care for our residents. 2. During an observation on 12/6/21, at 10:10 AM, in Resident 330's room, in the memory unit, Resident 330 was observed in bed, unshaven, unkempt in appearance, in stained hospital scrub bottoms, a t-shirt, and a sweatshirt. During a concurrent observation and interview on 12/7/21, at 10:39 AM, with NA 2, in the hallway by Nurses' Station 4, Resident 330 was observed propelling himself in a wheelchair around the unit and outside area looking for a bus stop. Resident 330 was observed wearing the same stained hospital scrub pants he was wearing the previous day. NA 2 stated, he was assigned to care for Resident 330 today but, he stated I don't know him too well. NA 2 stated, Resident 330 was independent in ADLs. NA 2 stated, he would watch residents who were somewhat independent for completion of ADLs but was unable to state if Resident 330 had brushed his teeth or knew to put on clean clothes this morning. NA 2 acknowledged that Resident 330 did not have the cognitive ability to independently remember to perform these ADLs without prompting. NA 2 stated, Resident 330 did not have a toothbrush and most likely had not brushed his teeth since admission. NA 2 was unable to state if Resident 330 had received a shower since admission [DATE]) for six days. During a review of Resident 330's Point of Care ADL Category Report (MDS 3.0), dated 11/8/21 through 12/8/21, the Point of Care ADL Category Report (MDS 3.0), indicated under bathing 8[Activity did not occur]. 3. During an interview on 12/6/21, at 12:29 PM, with Resident 57, Resident 57 stated, she does not get bathed and never gets to take a shower when she wants. Resident 57 stated, this makes her feel sad and dirty. During a concurrent interview and record review, on 12/7/21, at 9:45 AM, with NA 1, Resident 57's medical record (MR) was reviewed. NA 1 could not find documentation of the last time Resident 57 was bathed or showered. NA 1 stated, Resident 57 should have been on the shower schedule the day before (Monday - 12/6/21) because she is in A bed. NA 1 verified Resident 57 was not showered and was unable to offer an explanation. 4. During an interview on 12/6/21, at 12:45 PM, with Resident 64, Resident 64 stated, she does not get a bath very often. Resident 64 stated, staff tell her they are too busy to bathe her. Resident 64 stated, she wants to take a shower and it is embarrassing to her not to shower. During an interview on 12/7/21, at 9:37 AM (next day), with Resident 64, Resident 64 stated, she still has not received a bath or a shower. Resident 64 stated, she pooped on herself yesterday and has not been able to clean herself. Resident 64 stated, she is embarrassed and thinks she smells and she had requested staff to bring her wipes, but they haven't yet. During an interview on 12/7/21, at 10:13 AM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated, residents do not get baths or showers like they should because we are always short staffed. 5. During an observation on 12/7/21, at 11 AM, in the hallway in the memory unit, Resident 103 was sitting in her wheelchair with dripping yellow fluid from her wheelchair to the floor. Resident 103 seemed confused and unaware she was dripping fluid. During a review of Resident 103's Minimum Data Set, dated [DATE], the MDS indicated, Resident 103 required limited assistance with supervision and with toileting. 6. During an observation on 12/7/21, at 9:05 AM, in Resident 111's room, Resident 111 was attempting to get out of bed. Staff was observed walking by and did not acknowledge Resident 111. During an interview on 12/7/21, at 10:02 AM, with NA 2, NA 2 stated, they do not get Resident 111 up. NA 2 stated, Resident 111 usually refuses to get up so she is no longer offered to get up. During a review of Resident 111's MDS, dated [DATE], the MDS indicated, Resident 111 required extensive assist with one person physical assistance with transfers. 7. During an interview on 12/7/21, at 10:20 AM, with Resident 102, Resident 102 stated, he has not been showered in over a week and it's always too much trouble for the staff and they never want to do it. During a concurrent interview and record review on 12/8/21, at 11:59 AM, with Resident 102 and CNA 5, Resident 102's medical record (MR) was reviewed. CNA 5 could not find documentation of the last time Resident 102 was bathed or showered. CNA 5 stated, she was caring for Resident 102 today and had not showered or bathed him. Resident 102 stated, he would at least like a bed bath, as it would make him feel better. During an interview on 12/8/21, at 12:08 PM, with CNA 4, CNA 4 stated, residents are only given a choice of whether to bathe or shower on their scheduled shower days. CNA 4 stated, baths and showers do not happen if they are short staffed. During an interview on 12/8/21, at 3:45 PM, with DON, DON stated, his expectation would be for residents to get showered or bathed on their scheduled day unless they refuse. DON stated, if the resident chooses to take a bath or shower on another day, then staff should accommodate their request. During a review of the facility policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, dated 3/18, the P&P 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.

CONCERN (E)

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Provide activities for Resident 111 and Resident ...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Provide activities for Resident 111 and Resident 25. 2. Complete activities assessment for Resident 129. These failures had the potential to result in affecting residents' psychosocial well-being. Findings: 1. During an observation on 12/6/21, at 10 AM, in Resident 111's room. Resident 111 was in bed attempting to get up from bed. Staff walking by and was ignoring Resident 111. Resident 111 had a floor mat at bedside. During a review of Resident 111's Activity Attendance Sheets (AAS-activity log), dated 11/6/21 until 12/6/21, the AAS indicated, Resident 111 was not provided or offered with activities. Resident 111's Care Plan, dated 8/23/21, indicated, Resident is to receive bedside visits, even if she is asleep, due to behavior control. When resident is woken up, she has episodes of accelerated aggressive behavior, yelling, hitting staff, running barefoot and banging on windows. During an observation on 12/6/21, at 10 AM, in Resident 25's room, Resident 25 was lying in her bed staring at the ceiling. Resident 25 was verbally responsive but unable to answer questions. During a review of Resident 25's AAS, dated 11/2/21 until 12/6/21, the AAS indicated, Resident 25 was not provided or offered with activities. Resident 25's Care Plan, dated 11/29/17, indicated, [Resident 25] enjoys spending most of her day about the facility, listening to classical music. Resident also loves to dance. Resident loves to be around animals such as dogs and cats. Resident enjoys keeping house clean, and checking out men, resident also loves to paint, and write poetry. 2. During an observation on 12/6/21, at 10:05 AM, in the hallway, Resident 129 was walking around back and forth in the hallway. During a concurrent interview and record review on 12/8/21, at 12:43 PM, with Activity Director (AD), AD stated, Resident 111 and Resident 25 was not provided with activities and Resident 129 had no documented initial activity assessment within 14 days. AD stated, she is new to her position and was unable to catch up with documentations. Resident 129's Face Sheet dated 11/19/21, the FS indicated, Resident 129 was admitted on [DATE] (19 days ago). During a review of the facility's policy and procedure (P&P) titled, Activity Assessment undated, the P&P indicated, 1. Within 14 days of a resident's admission to the facility, an activity assessment will be conducted to help develop activities plan that reflects the choices and interests of the resident. 5. Each resident's activities care plan shall relate to his/her comprehensive assessment and should reflect his/her individual needs.

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

During a concurrent interview and record review with Restorative Nursing Aide (RNA) 1 and RNA 2 on 12/9/21, at 10:26 AM, three binders containing residents' RNA Flowsheets (RNAFs), dated 12/2021, were...

Read full inspector narrative →

During a concurrent interview and record review with Restorative Nursing Aide (RNA) 1 and RNA 2 on 12/9/21, at 10:26 AM, three binders containing residents' RNA Flowsheets (RNAFs), dated 12/2021, were reviewed. There was no documented evidence in the RNAFs from 12/1/21 to 12/9/21 that residents (including Resident 25, 27, 95, 35, 10, 21, 20, 37, 17, 53, and 64), had received RNA services. The RNAFs were blank from 12/1/21 to 12/9/21. RNA 1 and RNA 2 verified the findings. RNA 2 stated, Based on documentation, nothing has been done this week. RNA 1 stated at the beginning of every month, the RNAs print residents' RNAFs, containing the physician's orders (PO) for RNAs tasks, and place them in binders designated by Nurses' stations. RNA 1 stated, her duties included ambulating (walking) with residents, putting on splints (splints are used to prevent contraction of muscles in residents who are paralyzed or immobile), performing range of motion exercises (used to maintain a resident's flexibility and prevent muscle wasting) for both upper and lower extremities, sitting to standing exercises (to maintain strength and promote safety), and assisting residents to exercise using an arm and leg pedal machine. RNA 1 stated, there are typically two RNAs on the daily schedule. POs are written for residents for the frequency of the RNA treatment based on their individual needs. Some activities are performed daily, like splint placement, and others are performed several times a week. RNA 1 stated, No one does my job if I get pulled (to work on the floor as a CNA [Certified Nursing Assistant]). RNA 1 stated, . there is an impact on residents. RNA 1 stated, a resident used to have really good range of motion in her lower extremities and now I have to help her more. RNA 1 stated, she was having to assist on Station 4 today [with CNA duties] but I will try to get done what I can today. RNA 2 stated, Resident 107 used to be able to ambulate and now she cannot. RNA 2 stated, the RNAs are getting pulled almost every day to work on the floor as CNA's and no one is doing the RNA jobs when the RNAs are pulled. During a concurrent interview and record review on 12/9/21, at 11:24 AM, with Administrator and Director of Nursing (DON), three binders containing residents' RNAFs, dated 12/21, were reviewed. RNAFs indicated they were blank from 12/1/21 to 12/9/21, except for one day on a few residents. DON stated, I see a lot of blanks [indicated RNA services were not performed]. Administrator confirmed the findings. DON stated, sometimes the RNAs are being pulled to be CNAs. 2. During a concurrent observation and interview on 12/9/21, at 1:28 PM, in Resident 27's room, Resident 27 was observed in bed and seemed sleepy. Resident 27 stated, I haven't been getting any exercises since July. During a review of Resident 27's RNAFs, dated 12/21, the RNAFs indicated: a. RNA program for BUE 2x a week as tolerated involving PRE's on all available planes as tolerated necessary to maintain muscle strength and ROM after d/c; b. RNA program - Ambulation with FWW (front wheeled walker) at SBA (stand by assistance) distance as tolerated for 2x/wk to preserve current functional mobility; c. RNA program- BLE pre's using 2# . done on all planes as tolerated for 2x/wk to preserve current level of function. No documented evidence Resident 27 received RNA services from 12/1/21 to 12/9/21. 3. During a concurrent observation and interview on 12/9/21, at 1:36 PM, in Resident 95's room, Resident 95 was observed in bed with a blank look on her face. Resident 95 stated, she thought she was in the hospital, did not know date and year, and could not remember if she was getting exercises. During a review of Resident 95's RNAFs, dated 12/21, the RNAFs indicated: a. Establish RNA program for BUE 3x a week as tolerated . on all available planes necessary to maintain muscle strength and ROM after d/c (discharge). b. RNA 2x/wk for ambulation with 4WW (4 wheeled walker) x SBA x 350' (feet - unit of measurement) or as tolerated to maintain current functional levels in gait. No documented evidence Resident 95 received RNA services from 12/1/21 to 12/9/21. 4. During a concurrent observation and interview on 12/9/21, at 1:42 PM, in Resident 35's room, Resident 35 was observed in bed, leaning to his left with his head against the bed rail. Resident 35 stated, the last time he did exercises was three weeks ago. Resident 35 stated, When I don't get exercises it makes me feel like I don't want to do things. I used to be able to reach for the books up high, but now I have to get the books that are lower. I wish I was getting exercises; I was losing my balance. During a review of Resident 35's RNAFs, dated 12/21, the RNAFs indicated: a. RNA program 2x/wk for ambulation with 4WW x 150' or as tolerated requiring SBA to assist patient in maintaining current functional levels. b. RNA program for BUE 3x a week as tolerated involving BUE on all available planes as tolerated necessary to maintain muscle strength and ROM after d/c. No documented evidence Resident 35 received RNA services from 12/1/21 to 12/9/21. 7. During a concurrent observation and interview on 12/9/21, at 1:59 PM, in Resident 21's room, Resident 21 was observed performing exercises in his room. Resident 21 stated, Exercises [by RNAs] stopped more than two months ago. I couldn't walk when I got here. My coordination is better. I'm ready for my exercises. I do a little bit of exercises on my own. During a review of Resident 21's RNAFs, dated 12/21, the RNAFs indicated: a. RNA program for BUE 2x a week as tolerated involving PREs on all available planes as tolerated necessary to maintain muscle strength and ROM. No documented evidence Resident 21 received RNA services from 12/1/21 to 12/9/21. 10. During a review of Resident 20's RNAFs, dated 12/21, the RNAFs indicated: a. RNA 2x/wk for ambulation with fww (front wheeled walker) x 10' or as tolerated requiring MOD A (modified assistance) to maintain patient's functional mobility and weight bearing tolerance; b. RNA 2x/wk for BLE ROM ex (exercises) x 10 reps x 3 sets all planes as tolerated to maintain joint integrity; c. RNA program for BUE 2x a week as tolerated involving AARONE/AROME on all available planes as tolerated necessary to maintain muscle strength and ROM after d/c. No documented evidence Resident 20 received RNA services from 12/1/21 to 12/9/21. 11. During a review of Resident 37's RNAFs, dated 12/21, the RNAFs indicated: a. RNA 2x/wk for BLE ambulation x 150' or as tolerated; b. RNA 2x/wk for BLE AROM 10 reps x 3 sets of hip flexor, knee extension and ankle pumps; c. RNA program for BUE 2x a week as tolerated involving PRE's on all available planes as tolerated necessary to maintain muscle strength and ROM. No documented evidence Resident 37 received RNA services from 12/1/21 to 12/9/21. 12. During a review of Resident 17's RNAFs, dated 12/21, the RNAFs indicated, RNA Program- Sit to stand exercises, weight shifting and LE ROM 3 x per week as tolerated. No No documented evidence Resident 17 received RNA services from 12/1/21 to 12/6/21. 13. During a review of Resident 64's RNAFs, dated 12/21, the RNAFs indicated the resident had PO for RNA services. The RNAFs indicated no RNA program provided from 12/1/21 to 12/9/21. RNA 1 and RNA 2 verified findings. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated 7/17, the P&P indicated, Policy Statement. Residents will receive restorative nursing care as needed to help promote optimal safety and independence. Policy Interpretation and Implementation. 1. Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative service (e.g., physical, occupational, or speech therapies) . 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care. 6. Restorative goals may include, but are not limited to supporting and assisting the resident in: a. Adjusting or adapting to changing abilities; b. Developing, maintaining or strengthening his/her physiological [physical body] and psychological [mental and emotional] resources; c. Maintaining his/her dignity, independence and self-esteem; and d. Participating in the development and implementation of his/her plan of care. Based on observation, interview, and record review, the facility failed to provide RNA (Restorative Nursing Assistant) services (specific treatments to residents so as to restore and maintain the strength, coordination, and skills to ambulate and perform functional activities of daily living) for 10 of 82 sampled residents (Resident 25, Resident 27, Resident 95, Resident 35, Resident 10, Resident 21, Resident 20, Resident 37, Resident 17, and Resident 64). This failure had the potential for residents to experience decline in mobility and function. Findings: 1. During an observation on 12/6/21, at 10 AM, in Resident 25's room, Resident 25 was lying in bed staring at the ceiling. Resident 25 was verbally responsive but unable to answer questions. During an observation on 12/7/21, at 9 AM, in Resident 25's room, Resident 25 was lying in her bed staring at the ceiling talking to no one. During an interview on 12/7/21, at 10:02 AM, with Nursing Assistant (NA) 2, NA 2 stated the staff do not get Resident 25 up out of bed. NA 2 stated he had not seen Resident 25 participating in RNA the program. During a review of Resident 25's RNA Flowsheet (RNAF - flowsheet used to document when RNA services are completed) dated 12/21, the RNAF indicated: a. RNA program 3x/week for B (bilateral-both) LE (lower extremity-legs) PROMEs (passive range of motion exercise done by the RNA) on all available plane for 10 reps (repetitions) x 3 sets continuous. b. RNA program 7x/week for L (left) ankle AFO (ankle foot orthosis-a brace, usually made of plastic, that is worn on the lower leg and foot to support the ankle, hold the foot and ankle in the correct position and correct foot drop) for 4 hours or as tolerated. c. RNA program for B UE (upper extremities-arms) involving AROME (active range of motion exercises-resident moves by himself) on all available planes 2x a week as tolerated, necessary to maintain muscle strength and ROM (range of motion) after d/c (discharge). No documented evidence RNA services were provided from 12/1/21 until 12/6/21.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure one Hospice Registered Nurse (HRN) was trained to wear personal protective equipment (PPE - gown, gloves, and masks) i...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure one Hospice Registered Nurse (HRN) was trained to wear personal protective equipment (PPE - gown, gloves, and masks) in the yellow unit [with residents admitted to the facility as Persons under investigation for COVID 19 infection]. This failure had the potential to result in the spread of infection to residents, staff, and visitors. Findings: During an observation on 12/6/21, at 10:41 AM, several signs were posted on the door leading to the COVID 19 (respiratory infection) yellow unit. The signs indicated PPE to be worn. One yellow sign posted on the outer door to the unit, and on the wall outside of the residents' rooms indicated, Yellow Unit change gloves and gowns between residents. Practice resident source control. A second yellow sign indicated, Yellow Unit transmission-Based Precautions required personal protective equipment upon room entry N 95 facemask (particulate filtering face piece respirator), eye protection (face shield or goggles) gown gloves. During a review of the facility document titled Midnight Census Report, dated 12/6/21, indicated, Resident 533 received hospice services and Resident 530 was not receiving hospice services. During an interview on 12/6/21, at 10:57 AM, with Licensed Vocational Nurse (LVN) 6, LVN 6 stated, It's expected for staff to put on the full PPE when entering the unit. and wear full PPE when entering a resident room. During an observation on 12/6/21, at 12:15 PM, on the yellow unit, a HRN was observed exiting Resident 533's room and entering Resident 530's room without PPE. During an interview on 12/6/21, at 12:36 PM, with the Director of Nursing (DON), DON stated, staff should put on PPE when entering residents' room on the yellow COVID unit. During an interview on 12/6/21, 12:54 PM, with HRN, HRN stated, I was not aware I needed a gown. HRN stated, I should have seen the signs and worn a gown. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment, dated 10/2018, indicated, 7. Visitors and resident who are asked to comply with transmission-based precautions are educated on the proper use of PPE and provided with equipment at no charge.

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure: 1. One reach in refrigerator was maintained in good working condition. 2. The dish machine was maintained in good wo...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure: 1. One reach in refrigerator was maintained in good working condition. 2. The dish machine was maintained in good working condition. These failures had the potential to place residents at risk for food borne illnesses. Findings: 1. During an observation on 12/6/21, at 10:18 AM, next to the exit door in the kitchen, a reach in refrigerator that stored health shakes and juices, among other things, had a white towel underneath the reach in refrigerator. During an interview on 12/6/21, at 10:19 AM, with [NAME] 1 in the kitchen, [NAME] 1 stated, The towel underneath the reach in refrigerator is due to a leak and to prevent water from going into the hallway [where residents and staff walk]. The Maintenance Director [MD] is aware of the situation. During an interview on 12/6/21, at 11:45 AM, with MD, the MD verified the reach in refrigerator had a leaking issue and was not maintained in good repair. MD stated, It is on its last leg and needs to be replaced. There is a heated pan below refrigerator that causes any leaks to evaporate. The towels on the floor are there because there is a leak and heated pan is not functioning. During a review of the facility's reach in refrigerator manufacturer's operations manual titled, Continental Refrigerator installation and Operations manual Reach-Ins & Roll -Ins Refrigerators, Freezers & Warmers (RIOM), the RIOM indicated, TROUBLESHOOTING GUIDE, Problem: Water leak inside unit; Probable Cause: 4. Defective drain pan. Correction: 4. Replace. 2. During an observation on 12/6/21, at 10:35 AM, in the kitchen, there were large condensation droplets covering the vent on the ceiling in the dish machine area. During an observation and interview on 12/6/21, at 10:35 AM, with Dietary Aide (DA) 1 and DA 3, in the kitchen, the dish machine's wash water temperature gauge indicated 138 degrees F (Fahrenheit-a unit of measurement). DA 1 and DA 3 verified the temperature gauge indicated 138 degrees F. DA 1 stated the dish machine's wash water temperature should be between 140-160 degrees F. DA 1 ran another load of dirty dishes and the dish machine's wash water temperature remained at 138 degrees F. DA 1 stated the dish machine had been continuously in use since 8:30 AM. DA 1 and DA 3 verified the dish machine's water temperature reached 138 degrees F. During a review of the data plate affixed on the dish machine, the manufacturer's instructions indicated, the wash water to reach 140 degrees F. During an interview on 12/6/21, at 11:26 AM, with Assistant Dietary Manager (ADM), ADM stated, she thought there was a leak around the sink of the dish machine. ADM stated, the dish machine needed to be repaired. ADM stated, the MD was aware the dish machine needed to be repaired. The ADM stated, the condensation on the vent, located on the ceiling, was related to dish machine not working properly. During an interview on 12/6/21, at 11:38 AM, with MD, MD stated, the dish machine was not maintained in good repair. MD stated, The dish machine needs to be repaired. It is leaking and dripping. And sweating over the vent is due to the dish machine needs to be repaired or replaced. They are in the process of trying to get it replaced. During a review of the facility's policy and procedure (P&P) titled, Dish Washing, dated 2/16/21, the P&P indicated, The dishwasher will be kept clean and in good working order.

CONCERN (E)

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

Deficiency F0912 (Tag F0912)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide the minimum square footage as required by the regulation in 1...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide the minimum square footage as required by the regulation in 11 of the facility's bedrooms. This failure had the potential to affect the care the residents receive in these rooms. Findings: During a general observation of the facility on 12/6/21, at 11 AM, 11 of 62 rooms did not provide the minimum square footage (sq. ft.) as required by the regulation (80 sq. ft. per resident for multiple resident rooms). Although they did not provide the minimum square footage as required by regulation, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage were adequate. Bedside stands were available. There was sufficient space for nursing care and for residents to ambulate or use wheelchairs. Toilet facilities were accessible. room [ROOM NUMBER]-237.3 sq. ft.-3 residents room [ROOM NUMBER]-226.8 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents room [ROOM NUMBER]-237 sq. ft.-3 residents During an interview with the Administrator, on 12/7/21, at 9 AM, she confirmed Rooms 41-51 did not provide the minimum square footage. The Administrator stated she will continue to request a waiver for Rooms 41-51.

CONCERN (E)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure staff received training on how to properly transport an oxygen E - tank (aluminum oxygen tank that contains compressed...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to ensure staff received training on how to properly transport an oxygen E - tank (aluminum oxygen tank that contains compressed oxygen gas). This failure had the potential to result in bodily harm to residents, staff, visitors, and the surrounding community. Findings: During a concurrent observation and interview on 12/06/21, at 12:21 PM, in the hallway of Nurses' Station 1, Licensed Vocational Nurse (LVN) 2 was observed carrying an oxygen E - tank by the stem using her right hand. LVN 2 entered the oxygen storage room with the oxygen E - tank. She was observed exiting the oxygen storage room carrying the oxygen E-tank with a gauge attached, using her left hand. LVN 2 stated, I have an oxygen tank in my hand. LVN 2 stated, she had seen other staff carrying the oxygen E - tank in the same manner and no one had trained her. During an interview on 12/06/21, at 12:26 PM, with LVN 6, LVN 6 stated, she would get a cart from the closet to transport the oxygen E - tank. During an interview on 12/06/21, at 12:36 PM, with Director of Nursing (DON), DON stated, his expectation was for staff to use a cart when transporting oxygen in the facility. A facility policy and procedure for transporting oxygen was requested, none was provided. During an interview on 12/7/21, at 12:55 PM, with the Director of Staff Development (DSD), DSD stated, she does not train staff on how to properly transport oxygen. DSD stated, maintenance does the training on the initial tour of the facility. During an interview on 12/8/21, at 11:57 PM, with Maintenance Director (MD), MD stated, he provides the newly hired staff a tour of the facility and the facility grounds. MD stated, I don't train them on how to transport oxygen, I show them where the oxygen storage is. I believe that's nursing; I don't train them on that [safely transporting oxygen E tanks]. During a review of LVN 2's Emergency Tour Questionnaire, undated, the Emergency Tour Questionnaire indicated, 9. Where is the oxygen tank located? NOTE: Insure (sic) all E Tanks are in the proper holders . During a review of the facility's oxygen E - tank provider document titled, Oxygen, compressed Safety Data Sheet P-4638, revision date 10/21/2016, indicated, Section 7: Handling and storage 7.1 Precautions for safe handling : . Protect cylinders from physical damage: do not drag, roll, slide, or drop . When moving cylinders, even for short distances, use a cart (trolley, hand truck, etc.) designed to transport cylinders .

CONCERN (F)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the daily needs of residents. This failure resulted in showers not being completed f...

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet the daily needs of residents. This failure resulted in showers not being completed for residents and RNA (Restorative Nursing Assistant) services (specific treatments to residents so as to restore and maintain the strength, coordination, and skills to ambulate and perform functional activities of daily living) not being completed per physician orders. This failure also has the potential to result in all resident having unmet physical and psychosocial needs and decline in health status. Findings: 1. During an interview on 12/6/21, at 12:45 PM, with Resident 64, Resident 64 stated, she does not get a bath very often. Resident 64 stated staff tell her they are too busy to bathe her. Resident 64 stated, she wants to take a shower and it is embarrassing to her not to shower. During an interview on 12/7/21, at 9:37 AM (next day), with Resident 64, Resident 64 stated, she still has not received a bath or a shower. Resident 64 stated, she pooped on herself yesterday and has not been able to clean herself. Resident 64 stated, she is embarrassed and thinks she smells and she had requested staff to bring her wipes, but they haven't yet. During an interview on 12/7/21, at 10:13 AM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated, residents do not get baths or showers like they should because we are always short staffed. 2. During an interview on 12/7/21, at 10:20 AM, with Resident 102, Resident 102 stated, he has not been showered in over a week and it's always too much trouble for the staff and they never want to do it. During an interview on 12/7/21, at 11:10 AM, with Nursing Assistant (NA) 2, NA 2 stated, We are short staffed, we have 15 residents each and we are unable to give the adequate care for our residents. During a concurrent interview and record review on 12/8/21, at 11:59 AM, with Resident 102 and CNA 5, Resident 102's clinical record was reviewed. CNA 5 could not find documentation of the last time Resident 102 was bathed or showered. CNA 5 stated, she was caring for Resident 102 today and had not showered or bathed him. Resident 102 stated, he would at least like a bed bath, as it would make him feel better. During an interview on 12/8/21, at 3:45 PM, with Director of Nursing (DON), DON stated, his expectation would be for residents to get showered or bathed on their scheduled day unless they refuse. DON stated, if the resident chooses to take a bath or shower on another day, then staff should accommodate their request. 3. During a concurrent interview and record review with Restorative Nursing Aide (RNA) 1 and RNA 2 on 12/9/21, at 10:26 AM, three binders containing residents' RNA Flowsheets (RNAFs), dated 12/2021, were reviewed. There was no documented evidence in the RNAFs from 12/1/21 to 12/9/21 that residents, had received RNA services. The RNAFs were blank from 12/1/21 to 12/9/21. RNA 1 and RNA 2 verified the findings. RNA 2 stated, Based on documentation, nothing has been done this week. RNA 1 stated, her duties included ambulating (walking) with residents, putting on splints (splints are used to prevent contraction of muscles in residents who are paralyzed or immobile), performing range of motion exercises (used to maintain a resident's flexibility and prevent muscle wasting) for both upper and lower extremities, sitting to standing exercises (to maintain strength and promote safety), and assisting residents to exercise using an arm and leg pedal machine. RNA 1 stated, there are typically two RNAs on the daily schedule. Some activities are performed daily, like splint placement, and others are performed several times a week. RNA 1 stated, No one does my job if I get pulled (to work on the floor as a CNA. RNA 1 stated, . there is an impact on residents. RNA 1 stated, a resident used to have really good range of motion in her lower extremities and now I have to help her more. RNA 1 stated, she was having to assist on Station 4 today [with CNA duties] but I will try to get done what I can today. RNA 2 stated, the RNAs are getting pulled almost every day to work on the floor as CNA's and no one is doing the RNA jobs when the RNAs are pulled. During an interview on 12/9/21, at 10:26 AM, with RNA 2, RNA 2 stated, she has been assigned 17 residents on Nurses' Station 1 in the past as a CNA. RNA 2 stated, regarding showering residents, I do the best I can. Sometimes I don't get to them and I pass them to the next shift. I try to get everyone up. Sometimes I can't get to showers at all. 4. During an interview on 12/8/21, at 11:45 AM, with Staffing Coordinator (SC), SC stated, she is responsible for staffing, along with the assistant directors of nursing and Director of Nursing (DON). SC stated, the staffing matrix is based on facility's census and acuity level (the amount of the medically related support needs of an individual as measured by an assessment). SC stated, the facility has been getting a lot of staff calling off for their shifts. During an interview on 12/8/21, at 12:08 PM, with CNA 4, CNA 4 stated, residents are only given a choice of whether to bathe or shower on their scheduled shower days. CNA 4 stated, baths and showers do not happen if they are short staffed. During an interview on 12/8/21, at 2:42 PM, with DON, DON stated, to fill the schedule when someone calls off, they pull the two MDS (Minimum Data Set assessment) nurses, the DSD (Director of Staff Development), infection preventionist, or the assistant director of nursing to cover shifts. DON stated, the number of residents a CNA can care for depends on the residents' acuity, but there is no acuity tool used in the facility. During an interview on 12/9/21, at 8:24 AM, with CNA 2, CNA 2 stated, he is assigned to care for 14 residents today. CNA 2 stated, in the past the average number of residents he was assigned to care for was seven or eight. CNA 2 stated, there are four residents who require assistance with meals and seven residents who require assistance to be showered today. CNA 2 stated, to pull a resident up in bed requires two people and he would prefer to have another CNA to assist instead of bugging the nurses. CNA 2 stated, the assignment is too much, but I try to do my best. During an interview on 12/9/21, at 9:16 AM, with LVN 9, in the yellow unit (residents in isolation requiring staff to put on personal protective equipment to enter residents' rooms), LVN 9 stated, there is one CNA assigned to care for 14 residents today. During a concurrent interview and record review on 12/9/21, at 9:28 AM, with SC, Daily Staffing Records (DSR) printed from the computer staffing program On Shift titled, PLUM- [name of facility]- [day and date of record]- Census- [census number], dated 11/9/21 and 12/1/21 through 12/3/21, were reviewed. The DSR indicated CNAs, LVNs, and Restorative Nursing Assistants (RNAs) work 12-hour shifts, starting at either 6 AM or 6 PM. The DSR indicated the following for 6 AM shifts: a. On 11/9/21: Census 120; one CNA called off on Nurses' Station 3 and was not replaced; no CNA were scheduled for Nurses' Station 1, so RNA 3 moved to Nurses' Station 1; RNA 1 called off; three LVNs scheduled, but one called off on Nurses' Station 2 and was not replaced; two RNAs scheduled to perform RNA duties. b. On 12/1/21: Census 134; No CNA was scheduled for Nurses' Station 1, so RNA 4 moved to Nurses' Station 1 to perform CNA duties; RNA 5 moved to Nurses' Station 2 to perform CNA duties; one light duty (has physician restrictions regarding lifting, pushing, or pulling and may be required to take extensive breaks.) c. On 12/3/21: Census 138; light duty CNA covering both Station 1 and 2; CNA called off on Nurses' Station 4; RNA 1 move to Station 4 to perform CNA duties; RNA 2 moved to Nurses' Station 1 to perform CNA duties; no RNA performing RNA duties today. SC confirmed the findings. SC stated, We have a lot of call offs. We move people around as needed. SC stated, RNAs are moved to the floor and she is not sure how their job gets done. SC stated, there are lots of people on light duty. SC stated, staffing is done by acuity but we don't really have a list for acuity. SC stated, Nurses' Station 1 is usually pretty demanding. During a review of the facility's Daily Assignment Sheet (DAS), Nurses' Station 4, dated 12/6/21, and the Midnight Census Report (MCR), dated 12/6/21, the DAS indicated the following CNA/NA room assignments and MCR indicated the number of residents occupying those rooms, as some beds were empty: CNA 8: 43A to 48B (16 residents) CNA 7: 48C to 53A (14 residents) NA 2: 53B to 58C (14 residents) CNA 6: 59A to 63C (16 residents). DAS validated by LVN 4, charge nurse on Nurses' Station 4. During a review of the facility's policy and procedure (P&P) titled, Staffing, dated 10/17, the P&P indicated, Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

CONCERN (F)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

Based on observation and interview, the facility failed to: 1. Ensure medications were stored at the right temperature ranges. This failure had the potential for the medications to lose their potency ...

Read full inspector narrative →

Based on observation and interview, the facility failed to: 1. Ensure medications were stored at the right temperature ranges. This failure had the potential for the medications to lose their potency and effectiveness, which could then affect all the residents who take these medications in not recieving the full effect. 2. Ensure the medication Controlled Substance Accountability Sheet was signed off after medication administration. This failure had the potential for unaccounted medications. Findings: 1. During a concurrent observation and interview on 12/7/21, at 8:56 AM, with Central Supply Personnel (CSP), CSP stated, she's responsible for maintaining the storage of the over-the-counter medications (OTC - medications that you can buy without prescription). The medication storage room in station one had a room temperature of 84 degrees F (Fahrenheit-measurement of temperature), there were two electric fans on. CSP stated, The electric fans were turned on due to the medication room gets too hot. The following were observed in the medication room in station one: a. One ADU (Automated dispensing unit - machine which provide secure medication storage). b. Three red bins in front of the ADU with medication supplies. c. The cupboards were filled with several OTC medication supplies. d. Two refrigerators for resident's food and medications. During an interview on 12/7/21, at 9 AM, with Registered Nurse (RN) 1, RN 1 stated, she checked the temperature but was unaware the temperature should be below 77 degrees F. During a review of an OTC medication label, the Aspirin (medication to thin the blood) indicated, Store at room temperature. During an interview on 12/7/21, at 9:57 AM, with Pharmacy Consultant (PC), PC stated, 84 degrees F for OTC medications to store at a room temperature is too warm. It should be 77 degrees [F] or below. During a review of the facility Med Room Station - Thermometer Log (MRSTL), dated 11/1/21 until 12/6/21, the MRSTL indicated, the room temperature range was 78 degrees F to 85 degrees F. During a concurrent observation, interview, and record review, on 12/8/21, at 10:36 AM, with LVN 1, a package containing Lorazepam (used to treat anxiety) 2 mg/ml (ml - milliliter, unit of measure) for Resident 431 was observed stored at room temperature inside the medication cart 1A located at Nurse Station one. The manufacture instructions on the packaging indicated, Store at cold temperature. Refrigerate at 2° (degree) - 8°C [Celsius - unit used to measure temperature] (36 ° to 46°F [Fahrenheit - unit used to measure temperature]. LVN 1 stated, the medication was on her cart already when she did her medication count around 6 AM that morning. During a concurrent observation, interview, and record review, on 12/8/21, at 4:20 PM, with LVN 3, a package containing the medication Lorazepam 2mg/ml oral concentrate ordered for Resident 18 was observed stored inside medication cart 3A located at Nursing Station 3. The manufacturer's instructions on the packaging indicated, Store at cold temperature. Refrigerate at 2° to 8° C (36 to 46°F). LVN 3 stated, she was not aware and she did not know how long the medication had been on the cart, but she had not placed it there. During a review of the facility's policy and procedure (P&P) titled, Storage of Medications, dated 8/14, the P&P indicated, Temperature: A. Medications and biological's are stored at their appropriate temperatures and humidity according to the United States Pharmacopoeia guidelines for temperature ranges. B. Medications requiring storage at room temperature are kept at temperatures ranging from 15 ° C (59°F) to 25 ° (77°F). Medications requiring refrigeration are kept in a refrigerator at temperatures between 2°C (36°F) and 8°C (46°F) with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label . 2. During a concurrent observation, interview, and record review, on 12/8/21, at 10:31 AM, with RN 1 and Licensed Vocational Nurse (LVN) 1, at the medication cart located at Nurse Station 1, The facility document titled, Controlled Substance Accountability Sheet was reviewed, Resident 530 had received Pregabalin (used to treat nerve pain) Capsule 50 milligram (mg - unit of measure) one capsule by mouth every 8 hours on 12/8/21 at 12 AM. The Controlled Substance Accountability Sheet indicated the medication was not signed out for the 12/8/21 for 8 AM dose. LVN 1 stated, I did give the 8 O'clock medication, I just missed signing it out. Resident 429's Controlled Substance Accountability Sheet, indicated Alprazolam (used to treat anxiety) 2 mg tablet every 6 hours as need. The medication was administered on 12/7/21 at 2100 [9 PM]. An observation of the medication bubble pack with LVN 1 revealed one tablet was missing. LVN 1 confirmed she had administered the tablet at 9 PM but had not signed the Alprazolam control sheet.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a concurrent observation and interview on 12/7/21, at 11:35 AM, in the kitchen, with the Assistant Dietary Manager (AD...

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a concurrent observation and interview on 12/7/21, at 11:35 AM, in the kitchen, with the Assistant Dietary Manager (ADM), a piece of white paper towel was used to wipe the internal ice storage bin cascading shield that the ice touches. The ADM confirmed the white paper towel became discolored with a black substance. The ADM confirmed the findings. The ADM stated, An outside vendor is in charge of cleaning the ice machine. During a concurrent observation and interview on 12/7/21, at 11:39 AM, with Registered Dietitian (RD) 1, in the kitchen, RD 1 substantiated that the extensive black substance on the white paper towel from the internal ice machine ice storage bin cascading shield was not clean. RD 1 stated, the Food and Nutrition Department did not have a role in the cleaning of the ice machine, other than cleaning the ice scoop. RD 1 stated, the maintenance department is responsible for cleaning of the ice machine including internal ice machine ice storage bin. During an interview on 12/8/21, at 11:26 AM, with Maintenance Director (MD), MD confirmed that the internal ice machine ice storage bin was dirty. MD stated there is black substance that has accumulated inside the ice storage bin. During a review of the ice machine manufacturer's product manual titled, Scotsman model CME 506 Sanitation and Cleaning provided by the facility, the document indicated, It is the user's responsibility to keep the ice machine and ice storage bin in a sanitary condition. Sanitize the ice storage bin as frequently as local health codes requires, and every time the ice machine is cleaned and sanitized. During a review of the facility's policy and procedure (P&P), titled, Ice machine Cleaning Procedures, dated 2/16/21, the P&P indicated, . Information about the operation, cleaning and care of the ice machine can be obtained from owner's manual, the manufacturer and /or in the directional panel on the inside of the ice machine.3. Clean inside of the ice machine with a sanitizing agent per manufacturer's instruction. Add instructions to your policies, or use manufacturer procedure to clean and sanitize the machine. Based on observation, interview, and record review, the facility failed to ensure: 1. The PHF/TCS (Potentially Hazardous Foods/Time Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria) was documented as being cooled down safely. 2. Food was labeled with resident name and date in the nourishment refrigerator at the nursing station. 3. Expired food located in the nourishment refrigerator at the nursing station was thrown away. 4. Wash water temperature of dish machine met manufacturer's guidelines. 5. The Internal ice machine ice storage bin was maintained in a sanitary condition. These failures had the potential to cause foodborne illness (illness resulting from contaminated food) to residents residing in the facility. Findings: 1. During a concurrent observation and interview on 12/6/21, at 10:15 AM, with [NAME] 1, inside the walk-in refrigerator, a stainless-steel pan with cooked Spanish rice, dated 12/6/21 was observed. [NAME] 1 stated, the Spanish rice was cooked at the facility on 12/4/21. [NAME] 1 stated, he removed the Spanish rice that was cooked on 12/4/21 into a fresh pan that morning, and then dated it as 12/6/21. He said it was left over and would be served to residents who request it daily. During a concurrent interview and record review, on 12/6/21, at 10:19 AM, with [NAME] 1, the Special Cool Down Log (SCDL) and Cool Down Log (CDL) dated, 12/21, were reviewed. The SCDL and CDL documents were blank. [NAME] 1 verified the Spanish rice should have been on the cool down log. [NAME] 1 verified he did not know if the food was safe, because there was no documentation that the rice was cooled down safely. During a review of the facility's policy and procedure (P&P) titled, Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS), dated 2018, the P&P indicated, POLICY: Cooked potentially hazardous foods shall be cooled and reheated in a method to ensure food safety. Potentially hazardous foods include: . This list includes tofu, meat, fish, poultry, cooked rice, beans, pasta, . When cooling down food, use the Cool Down Log to document proper procedure. 2. During a concurrent observation and interview on 12/7/21, at 9:18 AM, with Licensed Vocational Nurse (LVN) 4, in Nurses' Station 2, four unlabeled unopened yogurt beverages, 7 oz (ounces- a unit of weight), an unlabeled covered red bowl, and an unlabeled bag of cooked white rice were observed in the resident refrigerator. LVN 4 verified the items were unlabeled without the resident's name on them and should be thrown away. During a concurrent observation and interview on 12/7/21, at 9:28 AM, with Certified Nursing Assistant (CNA) 7, at Nurses' Station 4, 10 vanilla health shakes in the resident's refrigerator were observed. No date to discard after thawing was indicated on the cartons. The vanilla shake manufacturer guidelines indicated, Handling Instructions: Store frozen. Thaw under refrigeration [40 degrees F [Fahrenheit- a unit of measurement] or below]. After thawing, keep refrigerated. Use within 14 days after thawing. CNA 7 stated, I rely on the kitchen staff to do that [to write expiration dates on cartons and stocking the resident refrigerator]. During an interview on 12/7/21, at 10:26 AM, with Registered Dietitian (RD) 1, RD 1 stated, she was unaware that health shakes were being stored in the nourishment refrigerator at the nursing station. RD 1 confirmed that the kitchen staff do not have a responsibility to stock the nourishment refrigerators at the nurses' stations with the health shakes; therefore, there was not an established procedure to ensure they were used within 14 days after thawing at that location, as there was a system when stored in the kitchen. During an interview on 12/7/21, at 10:39 AM, with Dietary Aide (DA) 2, DA 2 stated, she only takes the snacks via cart to the units, but the nursing staff removes snacks from her cart and places in the resident refrigerator. During a review of the facility's policy and procedure (P&P) titled, Labeling and Dating of Foods, dated 2020, the P&P indicated, POLICY: All food items in the storeroom, refrigerator, and freezer need to be labeled and dated. During a review of the facility's policy and procedure (P&P) titled, Procedure For Refrigerated Storage, dated 2018, the P&P indicated, 14. Supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. Follow the manufacturer's recommendations (specifications) for shelf life. 3. During a concurrent observation and interview on 12/7/21, at 9:19 AM, with LVN 4, in Nurses' Station 2, four unopened yogurt beverages, 7 oz were observed in the resident refrigerator. Three of the unopened yogurt beverages had a manufactured typed date of [DATE] and the fourth yogurt had a manufactured typed date of [DATE]. LVN 4 verified the yogurts were expired and should be thrown away. During a concurrent interview and record review on 12/8/21, at 3:36 PM, with RD 1, a picture of the yogurts was reviewed. RD 1 verified the dates on the yogurts were expiration dates. 4. During an observation and interview on 12/6/21, at 10:35 AM, with DA 1 and DA 3, in the kitchen by the dish machine, the dish machine's water temperature gauge was observed at 138 degrees Fahrenheit (F) and verified by DA 1 and DA 3. DA 1 stated the dish machine's water temperature should be between 140-160 degrees F. The dish machine was used again to run another load of dirty dishes and the dish machine's wash water temperature remained at 138 degrees F. DA 1 and DA 3 verified the dish machine's water temperature reached 138 degrees F. During an observation on 12/6/21, at 10:40 AM, in the kitchen by the dish machine, the data plate affixed on the dish machine was observed. The data plate manufacturer's instructions indicated wash tank minimum temperature should be 140 degrees F. During a review of the facility's policy and procedure (P&P) titled, Dish Washing, undated, the P&P indicated, 9. The dishwasher will run the dish machine until the temperature is within the manufacturer's recommendations. According to the FDA Food Code 2017, To ensure properly cleaned and sanitized equipment and utensils, warewashing machines must be operated properly. The manufacturer affixes a data plate to the machine providing vital, detailed instructions about the proper operation of the machine including wash, rinse, and sanitizing cycle times and temperatures which must be achieved. (FDA Food Code 2017, 4-501.15 Warewashing Machines, Manufacturers' Operating Instructions.)

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) committee failed to identify, develop...

Read full inspector narrative →

Based on interview and record review, the facility's Quality Assurance Performance Improvement (QAPI- a data driven and proactive approach to quality improvement) committee failed to identify, develop, and implement a plan of action to correct deficiencies related to staffing shortages. This failure resulted in resident's care and safety being compromised. Findings: During an interview on 12/7/21, at 9:17 AM, with Nursing Assistant (NA) 1, NA 1 stated, she had 15 residents to take care of on this day and staff does the best they can. NA 1 stated, residents do not always get their scheduled bath/showers due to short staffing. During an interview on 12/7/21, at 10:13 AM, with Certified Nursing Assistant (CNA) 3, CNA 3 stated, resident's do not get care like they should, because they are always short staffed. During a concurrent interview and record review, on 12/9/21, at 9:57 AM, with Administrator, QAPI meeting minutes for the months of August 2021 and October 2021 were reviewed. The QAPI meeting minutes indicated, the topics being discussed were falls, skin integrity, and activities for the residents. Administrator stated, the facility meets quarterly to discuss QAPI topics. They pick topics based on ongoing issues in the facility. During an interview on 12/9/21, at 11:27 AM, with Administrator, Administrator stated, staffing for the facility has been an ongoing issue within the facility and that it has affected the care and safety of the residents currently residing in the facility. The Administrator stated, staffing shortages have not been discussed or included in the QAPI Plan or discussed at the meetings. During a review of the facility's policy and procedure (P&P) titled, Quality Assurance Performance Improvement Plan, dated 2/18/19, the P&P indicated, Our purpose is to provide excellent quality resident care and services. Quality is defined as meeting or exceeding the needs, expectations, and requirements of the patients while maintaining good resident outcomes and perceptions of care. Our nursing home has a Performance Improvement Program which systematically monitors, analyzes, and improves its performance to improve resident outcomes, it recognizes that value in healthcare is the appropriate balance between good measures, excellent care, and services.

VISALIA POST ACUTE

The Good

The Bad

The Ugly 74 deficiencies on record

Questions to Ask on Your Visit

Our Honest Assessment

About This Facility

What is Visalia Post Acute's CMS Rating?

How is Visalia Post Acute Staffed?

What Have Inspectors Found at Visalia Post Acute?

Who Owns and Operates Visalia Post Acute?

How Does Visalia Post Acute Compare to Other California Nursing Homes?

What Should Families Ask When Visiting Visalia Post Acute?

Is Visalia Post Acute Safe?

Do Nurses at Visalia Post Acute Stick Around?

Was Visalia Post Acute Ever Fined?

Is Visalia Post Acute on Any Federal Watch List?

VISALIA POST ACUTE

Strengths

Concerns