How many inspection deficiencies does STANLEY HEALTHCARE CENTER have?

STANLEY HEALTHCARE CENTER has 67 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at STANLEY HEALTHCARE CENTER?

STANLEY HEALTHCARE CENTER has a two-star staffing rating from CMS with 0.40 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 STANLEY HEALTHCARE CENTER located?

STANLEY HEALTHCARE CENTER is located in WESTMINSTER, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does STANLEY HEALTHCARE CENTER have?

STANLEY HEALTHCARE CENTER has 30 certified beds.

Who owns STANLEY HEALTHCARE CENTER?

STANLEY HEALTHCARE CENTER is a for profit - limited liability company facility and is part of the PROGRESSIVE HEALTH CARE CENTERS chain.

What questions should families ask when visiting STANLEY HEALTHCARE CENTER?

Families visiting STANLEY HEALTHCARE CENTER 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 STANLEY HEALTHCARE CENTER compare to other nursing homes?

STANLEY HEALTHCARE CENTER has a 3-star overall rating, which is average compared to other nursing homes in CA. Consider visiting multiple facilities before making a decision.

STANLEY HEALTHCARE CENTER

Name: STANLEY HEALTHCARE CENTER
Address: 14102 SPRINGDALE STREET, WESTMINSTER, CA, 92683, US
Telephone: (714) 893-0026
Rating: 3.0

14102 SPRINGDALE STREET, WESTMINSTER, CA 92683 · (714) 893-0026

For profit - Limited Liability company 30 Beds PROGRESSIVE HEALTH CARE CENTERS Data: November 2025

Trust Grade

55/100

#686 of 1155 in CA

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STANLEY HEALTHCARE CENTER nursing home in WESTMINSTER, CA - Photo 1 of 2

STANLEY HEALTHCARE CENTER nursing home in WESTMINSTER, CA - Photo 2 of 2

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Last Inspection: March 2025

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

Overview

Stanley Healthcare Center has received a Trust Grade of C, which means it is average and in the middle of the pack compared to other facilities. It ranks #686 out of 1155 in California, placing it in the bottom half of state facilities, and #50 out of 72 in Orange County, indicating only a few local options are better. The facility's trend is worsening, with issues increasing from 22 in 2024 to 24 in 2025. Staffing is a relative strength, as turnover is at 0%, which is significantly better than the California average of 38%. However, there are concerning incidents, such as a resident experiencing severe weight loss due to inadequate nutritional support and sanitation issues in the kitchen that could lead to foodborne illnesses. Overall, while there are some strengths in staffing stability, the facility has notable weaknesses that families should consider.

Trust Score: C
In California: #686/1155
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: Turnover data not reported for this facility.
Penalties: No fines on record. Clean compliance history, better than most California facilities.
Skilled Nurses: Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 67 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 22 issues

2025: 24 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

3-Star Overall Rating

Near California average (3.1)

Meets federal standards, typical of most facilities

Chain: PROGRESSIVE HEALTH CARE CENTERS

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 67 deficiencies on record

1 actual harm

Jun 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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary respiratory care and services were provided for four of four sampled residents (Residents 1, 2, 3 and 4). * The facility failed to ensure Resident 1 had an order to suction secretions. * The facility failed to ensure Resident 2's oxygen nasal cannula was stored in the bag according to the facility's P&P. * The facility failed to ensure Resident 3's nebulizer administration set-up was changed every seven days according to the facility's P&P. * The facility failed to ensure Resident 4's CPAP washable filter, mask, nasal pillows and tubing were cleaned according to the manufacturer's guideline and facility P&P while the resident was in the facility. These failures had the potential to negatively affect the residents' medical conditions. 1. Review of the facility's P&P titled Suctioning Upper Airway (Oral Pharyngeal Suctioning) revised on 10/2010 showed to verify there is a physician's order for this procedure. Review the physician's order for facility protocol for suctioning. Review of Resident 1's medical record was initiated on 6/19/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 11/19/24, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's care plan initiated 4/20/25, showed risk for infection related to cough and congestion with intervention to maintain a clear airway by encouraging resident to clear own secretion with effective coughing. If the secretions cannot be cleared, suction as ordered required to clear secretions. On 6/19/25 at 0808 hours, an observation was conducted of Resident 1 in the resident's room. Resident 1 had a suction machine on his night stand table connected with Yankauer suction tubing in a plastic bag dated 6/8/25, that was inside the night stand drawer. On 6/19/25 at 0832 hours, an observation of Resident 1 and a concurrent interview was conducted with the DSD. The DSD verified the Yankauer suction had some fluid residue, was used and the storage bag was dated 6/8/25. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the night shift LVN to change the Yankauer suction every week and label the and supposed to label the plastic bag with resident's name and date. In addition, review of Resident 1's Order Summary as of 6/22/25, failed to show a physician's order for suctioning. On 6/25/25 at 1530 hours, an interview and concurrent record review was conducted with the DON. The DON verified Resident 1's Order Summary failed to show an order to suction the resident. The DON stated there should be an order for suctioning of the airway. 2. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised on 11/2011 showed in infection control considerations related to oxygen administration, to keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. Review of Resident 2's medical record was initiated on 6/19/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 3/13/25, showed Resident 2 had no capacity to understand and make decisions. Review of Resident 2's Order Summary showed a physician's order dated 5/1/25, to administer oxygen at 2-5 liters per minute via nasal cannula as needed. Review of Resident 2's MDS assessment dated [DATE], showed resident had BIMS score of 3 indicating the resident had severe cognitive impairment. Review of Resident 2's plan of care failed to show a care plan was developed for the resident's use of the oxygen. On 6/19/25 at 0812 hours, an observation was conducted of Resident 2 in the resident's room. Resident 2's oxygen concentrator was turned off at the resident's bedside. The nasal cannula tubing was not properly stored in the plastic bag hanged on the oxygen concentrator and part of the tubing was out of the plastic bag and touching the floor. On 6/19/25 at 0825 hours, an observation and a concurrent interview was conducted with the DSD. The DSD verified the nasal cannula was not properly stored in the plastic bag. The DSD stated the nasal cannula tubing should be stored properly and should not touch the floor for infection control. The DSD removed the nasal cannula tubing. The DSD further stated she will replace the nasal cannula. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the nurses to store the entire nasal cannula tubing in the bag when not in use. 3. Review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection revised on 11/2011 showed in infection control considerations related to medication nebulizers/ continuous aerosol, store the circuit in plastic bag, marked with date and resident's name, between uses; and discard the administration set-up every seven days. Review of Resident 3's medical record was initiated on 6/19/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 3/13/25, showed Resident 3 could make needs known but could not make medical decisions. Review of Resident 3's MDS assessment dated [DATE], showed resident had BIMS score of 6 indicating the resident had severe cognitive impairment. Review of Resident 3's Order Summary showed a physician's order dated 5/31/25, to administer ipratropium-albuterol (a bronchodilator medication used to relax the muscles around the airways in the lungs, making it easier to breathe) inhalation solution 0.5-2.5 mg/ml 1 vial every four hours as needed for coughing or wheezing. On 6/19/25 at 0816 hours, Resident 3's nebulizer tubing was observed on the resident's nightstand in a plastic bag with no name and was dated 6/10/25. On 6/19/25 at 0820 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified Resident 3's nebulizer tubing was in the plastic bag with no name and was dated 6/10/25. On 6/19/25 at 1100 hours, an interview was conducted with the DON. The DON stated she expects the night shift LVN to change the nebulizer tubing every week and supposed to label the plastic bag with resident's name and date. 4. Review of the facility's P&P titled CPAP/ BiPAP Support dated 3/2015 showed under the general guidance for cleaning: to clean humidifier weekly and air dry; rinse washable filter under running water once a week to remove dust and debris; and mask, nasal pillows and tubing, clean daily by placing in warm, soapy water and soaking/ agitating for 5 minutes. Mild dish detergent is recommended. Rinse with warm water and allow it to air dry between uses. Review of Resident 4's closed medical record was initiated on 6/19/25. Resident 4 was admitted to the facility on [DATE] and was discharged to acute care hospital on 5/29/25. Review of Resident 4's H&P examination dated 3/13/25, showed Resident 4 could make needs known but could not make medical decisions. Review of Resident 4's MDS assessment dated [DATE], showed resident had BIMS score of 15 indicating the resident had intact cognitive function. Review of Resident 4's Order Summary dated 5/31/25 showed a physician's order dated 5/12/25, may use CPAP machine at bedside, pressure setting 4.0, oxygen at 2 liters per minute, no humidification, for sleep apnea. Further review of Resident 4's medical record failed to show evidence the CPAP's washable filter, mask, nasal pillows and tubing were cleaned while the resident was in the facility. On 6/19/25 at 1510 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified Resident 4 uses CPAP at night. The DON verified CPAP's washable filter, mask, nasal pillows and tubing were not cleaned while the resident was in the facility. The DON further stated she would provide in-service to the licensed staff.

May 2025 1 deficiency

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0628 (Tag F0628)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide written information to the residents about a bed-hold information upon the resident transferring to an acute care hospital for three of three sampled residents (Residents 1, 2, and 3). These failures had the potential for the residents not receiving accurate information to determine if they wanted a bed-hold and to return to the facility. Findings: Review of the facility'sP&P titled Bed-Holds and Returns revised March 2017 showed prior to a transfer, written information will be given to the residents and their representative that explains in detail the residents' rights and limitations regarding bed-holds, the reserve bed payment policy, and the per diem rate to hold a bed beyond the state's bed-hold period. Review of the facility's Bedhold Notification Upon Transfer form showed the form was to be completed upon transfer and to provide a copy to the resident or their responsible party. The form showed the resident, or their responsible party was notified of their options to hold the bed and had check boxes to show if a bed-hold was desired, not desired, not appliable, or not eligible for a bed-hold, but still desired to pay privately for a bed-hold. 1. Closed medical record review for Resident 1 was initiated on 5/29/25. Resident 1 was admitted to the facility on [DATE], and transferred to an acute care hospital on 5/17/25. Review of Resident 1's medical record failed to show the resident was provided information on the bed-hold options. 2. Medical record review for Resident 2 was initiated on 5/29/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's EHR census showed the resident went on an acute care hospital on a paid leave on 5/1/25, and returned to the facility on 5/5/25. Review of Resident 2's medical record failed to show the resident or her responsible party was provided with the information on their bed-hold options. 3. Medical record review for Resident 3 was initiated on 5/29/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's EHR census showed the resident went on an acute care hospital on a paid leave 4/30/25, and returned to the facility on 5/7/25. Review of Resident 3's medical record failed to show the resident or responsible party wasprovided with the information on their bed-hold options. On 5/29/25 at 1012 hours, an interview and concurrent medical record review for Residents 1, 2, and 3 was conducted with LVN 1. LVN 1 stated she was the nurse for Residents 1, 2, and 3, when they were transferred to the acute care hospitals. LVN 1 stated the facility obtained the physician's orders for the residents to have bed-holds if admitted to the acute care hospital. LVN 1 stated their process for the bed-hold wasafter receiving the notification from the acute care hospital the resident was being admitted , the LVN was then to call and ask if the resident or responsible party wanted a bed-hold. LVN 1 stated they did not provide anything in writing to the residents or their responsible partyabout bed-hold options. When asked what options LVN 1 discussed with the residents or responsible parties, LVN 1replied she only asked if they wanted a bed-hold and did not know any particulars about who was responsible for the bed-hold payments. On 5/29/25 at 1150 hours, an interview was conducted with the Administrator. The Administrator stated all the residents should be offered written information about the bed-hold options upon transferring out of the facility.

May 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 2) had the physician's orders for the indwelling urinary catheter use, care, and maintenance. This failure had the potential for the resident to develop indwelling urinary catheter related infection and/or complications. Findings: Medical record review for Resident 2 was initiated on 5/15/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's physician orders failed to show any orders for the indwelling urinary catheter use, care, and maintenance. On 5/15/25 at 1510 hours, Resident 2 was observed lying in bed, with a urinary drainage bag hanging on the left side of the resident's bed. On 5/15/25 at 1511 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 2 had an indwelling urinary catheter, and catheter care should be done every shift and documented in the TAR. LVN 1 reviewed Resident 1's medical record and verified there were no physician's orders for use of an indwelling urinary catheter, the catheter care and management. LVN 1 stated the resident should have the physician's orders for the indwelling urinary catheter use, catheter care, and management. On 5/16/25 at 0936 hours, an interview was conducted with the DON. The DON stated Resident 2 was admitted with an indwelling urinary catheter. The DON was informed and acknowledged the above findings.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Comprehensive Assessments (Tag F0636)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and closed medical record review, the facility failed to ensure the annual and discharge return- anticipated MDS assessments were completed within 14 calendar days after the ARD for the annual and discharge return anticipated assessments for one of two sampled residents (Resident 1). This failure had the potential of not identifying each resident's preferences and goals of care, functional and health status, strengths and needs, as well as offering guidance for further assessments when the health problems had been identified. Findings: Closed medical record review for Resident 1 was initiated on 5/16/25. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's Annual MDS assessment showed had an ARD of 4/25/25. The Annual MDS showed the status of the assessment was in progress and to be completed by 5/9/25 (seven days overdue), 21 days after the ARD of 4/25/25. Review of Resident 1's Discharge Return-Anticipated MDS had an ARD of 4/29/25. The Discharge Return-Anticipated MDS showed the status of the assessment was in progress and to be completed by 5/13/25 (three days overdue), 17 days after the ARD of 4/29/25. Review of Resident 1's progress note dated 4/29/25 at 1629 hours, showed Resident 1 was transferred to the acute care hospital. On 5/16/25 at 0952 hours, an interview and concurrent closed medical record review for Resident 1 was conducted with the DON. The DON stated Resident 1 was a long-term resident and was transferred to the acute care hospital on 4/29/25, with the anticipation of returning to the facility. The DON verified the above findings and stated the above MDS assessments for the annual and discharge return anticipated should have been completed within 14 calendar days of the ARD.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and medical record review, the facility failed to ensure the medical record was complete and accurately maintained for one of two sampled residents (Resident 2). * Resident 2's physician's order for wound care did not include the location of the wound. This failure had the potential for not providing necessary care and services due to incomplete medical records. Findings: Medical record review for Resident 2 was initiated on 5/15/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Skin and Wound Evaluation V7.0 dated 5/15/25, showed the resident had a Stage 3 pressure ulcer to the medial sacrum (bone at the base of the spine). Review of Resident 2's Order Summary Report showed a physician's order dated 5/15/25, to cleanse the Stage 3 pressure ulcer and surrounding DTI with normal saline, apply Betadine (an antiseptic solution) to the surrounding DTI tissue, and MediHoney (a wound care paste) to the Stage 3 wound, and cover with dry dressing daily and as needed. The order failed to show the location of the wound. On 5/16/25 at 0936 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 2's physician's orders and verified the resident's wound care order did not show the wound location but should have.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Infection Control (Tag F0880)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to maintain the infection control practices to help prevent the development and transmission of the diseases and infections for one of two sampled residents (Resident 2). * The facility staff failed to ensure the EBP was maintained for Resident 2 with an indwelling urinary catheter during incontinence care. This failure had the potential to spread infectious organisms to the other residents in the facility. Findings: Review of the facility P&P titled Enhanced Barrier Precautions dated August 2022 showed EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms to residents. Gloves and gowns are to be used while performing high contact resident care activities, including when performing resident hygiene and changing briefs. Medical record review for Resident 2 was initiated on 5/15/25. Resident 2 was admitted to the facility on [DATE]. On 5/15/25 at 1408 hours, an observation and concurrent interview was conducted with the DSD/IP in Resident 2's room. An EBP signage was posted outside the resident's doorway and showed everyone must wear a gown and gloves for high-contact resident cares including when providing hygiene and changing briefs. The DSD/IP stated the EBP was for Resident 2 since she had an indwelling urinary catheter. Upon entering Resident 2's room, CNA 1 and RNA 1 were observed changing Resident 2's incontinent briefs wearing only gloves. The DSD/IP verified the above findings and stated the CNA and RNA should be wearing isolation gowns when providing incontinent care for Resident 2.

Mar 2025 18 deficiencies

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility P&P review, the facility failed to ensure the services provided met the professional standards of care when LVN 2 failed to properly obtain the blood pressure for one of three residents (final sampled resident, Resident 3) observed for medication administration. This failure had the potential for the residents requiring blood pressure checks to have inaccurate readings. Findings: Review of the facility's P&P titled Blood Pressure, Measuring revised 2010 showed the steps in the Procedure section as follows: - To expose the resident's arm by rolling the sleeve up about five inches above the elbow. - To wrap the blood pressure cuff evenly around the upper arm, approximately one inch from the elbow. - When you locate the pulsation, place the diaphragm of the stethoscope firmly against the skin. Hold diaphragm in place with your hand. - With your free hand, pump air into the cuff by squeezing the bulb until you can no longer hear the pulsation. (Note: You must be watching the mercury level on the manometer while you are pumping the air in the cuff.) - When you hear the last pulsation sound, loosen the thumbscrew slowly to let the air out. Watch the mercury reading on the manometer. Listen for the first sound, note the number. This will be the top (systolic) reading. - To continue to listen for the pulsation sound and watch the mercury reading on the manometer. When you hear the last sound, note the number. This will be the lower (diastolic) reading. On 3/4/25 at 0919 hours, a medication administration observation was conducted with LVN 2 for Resident 3. LVN 2 was observed placing the blood pressure cuff and diaphragm of the stethoscope over Resident 3's upper arm and over his black long sleeve shirt to obtain the resident's blood pressure reading. Resident 3's blood pressure was 152/90 mm/Hg. On 3/4/25 at 1435 hours, an interview was conducted with LVN 2. LVN 2 verified she placed the blood pressure cuff and diaphragm of the stethoscope over Resident 3's black long sleeve shirt. LVN 2 verified the facility's process when obtaining the blood pressure was to place the blood pressure cuff and diaphragm of the stethoscope directly against the skin. LVN 2 stated placing the blood pressure cuff and diaphragm of the stethoscope over clothing could cause an inaccurate blood pressure reading and be difficult to hear. On 3/4/25 at 1444 hours, an interview was conducted with the DSD/IP. The DSD/IP stated the licensed nurses were trained regarding the process of correctly obtaining the blood pressure manually during their orientation skills training. The DSD/IP verified the correct process to obtain the blood pressure was the blood pressure cuff and diaphragm of the stethoscope was placed on the upper arm, directly on the skin. The DSD/IP also stated putting the diaphragm of stethoscope over clothing could give an inaccurate reading, if the licensed nurse was unable to hear the pulsation sound. On 3/5/25 at 0815 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 12 final sampled residents (Resident 8) who had limited mobility and ROM functions received the appropriate treatment and services to maintain or improve their ROM functions and prevent further decline in their ROM functions. This failure had the potential for Resident 8 to experience a decline in her physical abilities. Findings: Review of the facility's P&P titled Resident Mobility and Range of Motion revised July 2017 showed the residents will not experience an avoidable reduction in ROM. Residents with limited ROM will receive treatment and services to increase and/or prevent a further decrease in ROM. In addition, resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. On 3/3/25 at 0856 hours, an observation and concurrent interview was conducted with Resident 8. When asked about her experience at the facility, Resident 8 stated she had not received physical therapy since her admission to the facility. Resident 8 stated she requested for therapy to regain her ability to walk. Resident 8 further stated the DON had stopped by her room and stated she would speak to the PT. Medical record review for Resident 8 was initiated on 3/6/25. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 8's H&P examination dated 4/27/24, showed the resident could make her needs know but could not make medical decisions. Review of Resident 8's plan of care showed a care plan problem dated 2/10/25, addressing the resident's arthritis (joint inflammation) to the bilateral knees, hands and fingers with a goal for the resident to be free of complications related to arthritis (contractures, joint stiffness, swelling or decline in mobility). The interventions included to provide daily range of motion exercises both active and passive as tolerated. Review of Resident 8's Documentation Survey Report (intervention/tasks assigned to the CNAs) for March 2025 did not show documented evidence the ROM exercises were provided to Resident 8. Further review of Resident 8's medical record did not show the physician's orders for physical therapy or RNA services. In addition, there was no documented evidence the ROM exercises were provided to Resident 8. On 3/6/25 at 1027 hours, an interview was conducted with RNA 1. RNA 1 stated the PT wrote the order for the RNA services. RNA 1 also stated long-term residents were provided RNA services after being evaluated by the PT. RNA 1 verified Resident 8 did not receive RNA services. Additionally, RNA 1 stated Resident 8 was a long-term resident and had not been seen by the PT. On 3/6/25 at 1052 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 8 was not fully independent and needed assistance from the staff with transfers. CNA 2 stated the CNAs did not provide ROM exercises to Resident 8 and only the RNA provided the ROM exercises with the residents. CNA 2 stated the residents who did not qualify for PT to help maintain their ROM, the CNAs helped with maintaining the residents' ROM. CNA 2 verified there were specific ADL tasks assigned to the CNAs and these tasks were documented in the resident's EHR. However, CNA 2 was unable to provide documentation to show the ROM exercises for Resident 8 were done. On 3/6/25 at 1115 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 8 had limited movement to her lower extremities. LVN 1 verified the facility did not provide the ROM exercises to Resident 8. LVN 1 verified Resident 8's care plan and intervention showed to provide daily ROM exercises both active and passive as tolerated. LVN 1 stated Resident 8 did not have PT or RNA services ordered by the physician. LVN 1 verified there was no documentation to show the daily exercises, both active and passive, were provided to the resident by the CNAs or licensed nurses. On 3/6/25 at 1115 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 8 had limited ROM to the lower extremities. The DON acknowledged Resident 8 should be receiving daily exercises for the ROM. The DON verified there was no documentation from the RNA to show the daily exercises for active and passive ROM exercises were provided to Resident 8. The DON also verified there was no documentation from the CNAs showing Resident 8 had been receiving daily ROM exercises.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of one final sampled resident (Resident 3) reviewed for smoking remained free from accident hazards. * The facility failed to ensure Resident 3' smoking assessment was completed upon admission to the facility to determine if the resident was safe to smoke. This failure had the potential for the resident to sustain accidents and/or injuries. Findings: Review of the facility's P&P titled Smoking Policy revised July 2017 showed the residents who smoke must be assessed upon admission with a safe smoking assessment tool. On 3/3/25 at 1201 hours, an interview with was conducted with Resident 3 about his smoking privileges in the facility and how the facility staff had accommodated him. Resident 3 stated, they (the facility staff) take me out to the smoking area and wait with me while I smoke, there's an ashtray and they put the cover over me to keep me clean. On 3/3/25 at 1215 hours, an observation was conducted of the Smoking Patio. A fire extinguisher was observed inside the facility, close to the entrance of the Smoking Patio. A metal covered ashtray was also observed in the Smoking Patio. Medical record review for Resident 3 was initiated on 3/3/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 5/8/24, showed the resident had capacity to understand and make decisions. Further review of Resident 3's medical record failed to show the safe smoking assessment was completed for the resident. On 3/4/25 at 0958 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated the safe smoking assessment for the residents who smoked would be done upon admission to the facility. When LVN 2 was asked to show the documented safe smoking assessment for Resident 3, LVN 2 was unable to show the safe smoking assessment in Resident 3's medical record. LVN 2 further stated the facility just migrated to a different EHR application less than six months ago. On 3/4/25 at 1047 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged and verified the above findings.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of two final sampled residents (Residents 13 and 17) reviewed for oxygen therapy. * The facility failed to follow the physician's order for Residents 13 and 17's oxygen therapy. This failure had the potential for the residents to not receive the appropriate care and may negatively impact the residents' medical conditions. Findings: 1. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify there is a physician's order for this procedure, review the physician's orders or facility protocol for oxygen administration. On 3/3/25 at 0907 hours, during the initial tour of the facility, Resident 13 was observed lying in bed and receiving oxygen at 5 liters per minute via nasal cannula which was attached to the oxygen machine concentrator . Medical record review for Resident 13 was initiated on 3/3/25. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's H&P examination dated 2/20/25, showed Resident 13 had the capacity to understand and make decisions. Review of Resident 13's Order Summary Report for March 2025 showed a physician's order dated 2/18/25, to administer oxygen at 4 liters per minute via nasal cannula as needed to keep the oxygen saturation levels above 90%. On 3/4/25 at 0842 hours, an observation, interview, and concurrent medical record review was conducted with the DSD/IP. The DSD/IP verified Resident 13's oxygen machine concentrator was set at 5 liters per minute and the physician's order for the oxygen was to be administered at 4 liters per minute as needed for Resident 13. The DSD/IP acknowledged the findings and stated the facility staff should follow the physician's order for the oxygen administration for Resident 13. 2. On 3/3/25 at 0950 hours, during the initial tour of the facility, the nasal cannula for Resident 17 was observed on the resident's bed and Resident 17 was not observed in the room. On 3/4/25 at 1009 hours, an observation was conducted in Resident 17's room. Resident 17 was not observed in the room and the resident's nasal cannula was on the resident's bed. On 3/5/25 at 1316 hours, Resident 17 was observed sitting on her dual mobility walker and chair at the entrance of her room without oxygen. On 3/5/25 at 1327 hours, an observation and concurrent interview was conducted with Resident 17. Resident 17 verified she was to receive the oxygen continuously. Resident 17 stated she did not feel she needed to have the nasal cannula on when she was sitting down. Medical record for Resident 17 was initiated on 3/3/25. Resident 17 was admitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed a physician's order dated 8/29/24, to administer the oxygen at 2 liters per minute via nasal cannula continuously for dyspnea. Review of Resident 17's H&P examination dated 2/17/25, showed the resident could make her needs known but could not make medical decisions. On 3/5/25 at 1327 hours, an observation and concurrent interview were conducted with CNA 1. CNA 1 verified the above findings. CNA 1 stated Resident 17 was supposed to receive continuous oxygen at 2 liters per minute. CNA 1 stated the resident removed the nasal cannula because the resident did not like wearing it. CNA 1 further stated the CNAs did not document Resident 17's refusal to wear the cannula but would notify the licensed nurses. On 3/5/25 at 1335 hours, an observation, interview, and concurrent medical record review was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 was observed checking Resident 17's oxygen saturation level which was 82% on room air. On 3/5/25 at 1502 hours, a follow-up observation was conducted with LVN 2 for Resident 17. LVN 2 was observed rechecking Resident 17's oxygen saturation level which was 100% with oxygen at 2 liters per minute.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical review for Resident 1 was initiated on 3/3/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Safety Assessment for Siderail Usage dated 8/1/24, showed, No was documented for the alternative, least restrictive measures tried or considered and risk for entrapment. Review of Resident 1's plan of care showed a care plan problem dated 3/1/25, addressing the resident's moderate risk for falls due to confusion, incontinence, psychoactive drug use, lack of safety awareness, and a diagnosis of dementia. The interventions included to use the side rails as ordered. Review of Resident 1's Order Summary Report dated 3/4/25, showed a physician's order dated 8/28/24, for bilateral upper side rails up while in bed for mobility and repositioning. On 3/3/25 at 0800 and 1100 hours, Resident 1 was observed resting in bed with the bilateral side rails up (from head to waist). On 3/4/25 at 1230 hours, an interview and concurrent medical record review was conducted with the DSD/IP. The DSD/IP was asked about the alternative, least restrictive measures tried or considered prior to the installation of Resident 1's side rails. The DSD/IP stated no alternatives or least restrictive measures were tried and verified there were no care plan developed and risk for entrapment assessment completed to address the resident's use of side rails. Cross reference to F909, example #4. 3. On 3/4/25 at 0945 hours and 1212 hours, Resident 12 was observed in bed with the bilateral one-half upper side rails raised. Medical record review for Resident 12 was initiated on 3/4/25. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's H&P examination dated 10/20/24, showed Resident 12's diagnoses included advanced dementia and Parkinson's-type tremors. The H&P examination also showed Resident 12 had no capacity to make decisions. Further review of Resident 12's medical record failed to show a side rail assessment was completed for Resident 12. On 3/6/25 at 1035 hours, an interview and concurrent medical record review for Resident 12 was conducted with the DSD/IP. The DSD/IP verified Resident 12's side rail assessment was not completed. On 3/6/25 at 1042 hours, an interview and concurrent facility document review was conducted with the Maintenance Supervisor. When asked about the manufacturer's manual used to check the compatibility between Resident 12's bed and the installed side rails, the Maintenance Supervisor verbalized the facility did not have a manufacture's manual. Cross reference to F909, example #3. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure four of 12 final sampled residents reviewed for the side rail use (Residents 1, 12, 13, and 20) remained free from the accident hazards due to the use of side rails. * The facility failed to ensure the Facility Verification of Informed Consent for Resident 13 was accurately completed. The consent form had no physician's signature and date. Furthermore, the facility failed to ensure the physician's order was obtained for the use of the bilateral half side rails for Resident 13. * The facility failed to ensure a care plan was initiated for the use of the bilateral half side rails for Resident 20. * The facility failed to provide the manufacturer's manual for Resident 12's bed to show compatibility for the bed's side rails. In addition, Resident 12's assessment for the use of the side rails was not completed. * Resident 1's assessment for the side rails to attempt the least restrictive measures and the risk of entrapment were not completed. These failures had the potential risk for injuries to the residents. Findings: Review of the facility's P&P titled Proper Use of Side Rails revised date 12/2016 showed an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. The use of the side rails as an assistive device will be addressed in the resident care plan. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. Review of the facility's P&P titled Informed Consent revised date 8/8/11, showed before initiating the administration of the psychotherapeutic drugs, physical restraints, or the prolonged use of a device that may lead to the inability to regain use of a normal bodily function, the facility staff shall verify the resident's health record contains documentation that the resident was given informed consent for the proposed treatment or procedure. All of the informed consent verifications must be in writing prior to initiation of the treatment or procedure. Acceptable form is the Facility Verification of Informed Consent Form completed and signed by the prescribing physician. 1. Medical record review for Resident 13 was initiated on 3/3/25. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's Facility Verification of Informed Consent dated 11/13/24, showed the consent had missing physician's signature and date. Review of Resident 13's plan of care showed a care plan intervention dated 12/16/24, to use the bilateral half side rails to maximize independence with turning and repositioning in bed. Review of Resident 13's H&P examination dated 2/20/25, showed Resident 13 had a diagnosis of Alzheimer's disease and the capacity to understand and make decisions. Review of Resident 13's Order Summary Report dated 3/4/25, failed to show a physician's order for the use of the bilateral half side rails. On 3/3/25 at 0907 hours, during the initial tour of the facility, Resident 13 was asleep in bed with the bilateral half side rails elevated at the head of the bed. On 3/4/25 at 0836 hours, Resident 13 was observed lying in bed with the bilateral half side rails elevated. On 3/4/25 at 1110 hours, an observation and concurrent interview was conducted with the DSD/IP. The DSD/IP verified Resident 13 had the bilateral half side rails in place and stated there should be a physician's order and the informed consent should have been completed accurately and signed by the physician. Cross reference to F909, example #1. 2. On 3/3/25 at 0934 hours and 3/4/25 at 0851 hours, Resident 20 was observed lying in bed with the bilateral half side rails elevated at the head of the bed. Medical record review for Resident 20 was initiated on 3/3/25. Resident 20 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 20's Order Summary Report for March 2025 showed a physician's order dated 8/21/24, to apply the bilateral upper side rails while in bed for increased bed mobility and repositioning. Review of Resident 20's H&P examination dated 8/22/24, showed Resident 20 had the capacity to understand and make decisions. Review of Resident 20's plan of care failed to show a care plan problem addressing Resident 20's bilateral half side rails use. On 3/6/25 at 1013 hours, an observation and concurrent interview was conducted with the DSD/IP. The DSD/IP verified the above findings and stated there should be a care plan to address the resident's use of the side rails for the facility staff to be aware of how to care for the resident. Cross reference to F909, example #2.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration of medications for one of three residents (final sampled resident, Resident 8) observed for medication administration when: * LVN 1 failed to assess Resident 8's bowel status prior to administering a laxative (promotes bowel movements) medication as per the physician's order. This failure had the potential to negatively affect the resident's health conditions that could posed the risk for possible complications. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with the prescriber orders. On 3/4/25 at 0816 hours, a medication administration observation for Resident 8 was conducted with LVN 1. LVN 1 prepared and administered Resident 8's medications which included polyethylene glycol (laxative) powder 17 gm and Senna (laxative) 8.6 mg. LVN 1 administered the polyethylene glycol and Senna medications without assessing the resident's bowel status or checking the resident's medical record for her bowel elimination. Medical record review for Resident 8 was initiated on 3/4/25. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 4/27/24, showed the resident could make her needs known but could not make medical decisions. Review of Resident 8's Order Summary Report showed the following physician's orders: - dated 10/17/24, to administer polyethylene glycol 3350 oral powder 17 gm/scoop by mouth one time a day for bowel management; and to hold for loose stool. - dated 5/8/24, to administer Senna 8.6 mg one tablet by mouth two times a day for bowel management; and to hold for loose stool. On 3/4/25 at 0852 hours, an interview and concurrent medical record review was conducted with LVN 1 for Resident 8. When asked if LVN 1 had assessed the resident's bowel status prior to administering the laxative medications, LVN 1 verified she did not assess Resident 8's bowel status or check the resident's medical record for the resident's bowel elimination prior to administering the laxative medications. LVN 1 stated Resident 8 always wanted her laxatives and stool softeners. On 3/5/25 at 0824 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 1 was initiated on 3/3/25. Resident 1 was admitted to the facility on [DATE]. Review of the Note to Attending Physician/Prescribers dated 2/8/25, showed the CMS guidelines released on 11/2017 indicated PRN psychotropic medications were now limited to 14 days. If the PRN psychotropic order needed to be extended beyond 14 days, it must be justified by the physician. Please evaluate the following order for a stop date: lorazepam (antianxiety medication) 2 mg/ml, administer 0.5 ml every four hours as needed for anxiety. Further review of Resident 1's medical record failed to show documented evidence the facility had addressed the pharmacy recommendations for the resident's lorazepam medication. On 3/5/25 at 1210 hours, an interview and concurrent medical record review was conducted with the DSD/IP. The DSD/IP stated the facility had followed up with the physician regarding the pharmacist's drug regimen review recommendation for Resident 1's lorazepam medication. However, the DSD/IP acknowledged there was no documented evidence the pharmacy recommendation was followed up but assured the licensed nurses would contact the physician. The DSD/IP verified the above findings. On 3/5/25 at 1430 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 was asked if Resident 1 had experienced shortness of breath or episodes of anxiety. LVN 2 stated in the last two months, she had not observed the resident experiencing anxiety and had not administered the lorazepam during the day shift. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's identified drug recommendations were addressed for two of 12 final sampled residents (Residents 1 and 17). This failure posed the risk for the residents to have adverse consequences related to their medications. Findings: Review of the facility's P&P titled Medication Regimen Review revised 5/19 showed: - The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. - The attending physician documents in the medical record that the irregularity has ben reviewed and what (if any) action was taken to address it. 1. Medical record review for Resident 17 was initiated on 3/5/25. Resident 17 was admitted to the facility on [DATE]. a. Review of Resident 17's Order Summary Report showed a physician's order dated 9/6/24, to administer Preparation H (temporarily relieve swelling, burning, pain, and itching caused by hemorrhoids) 0.25 mg per rectal every six hours for hemorrhoids. Review of Resident 17's Consultant Pharmacist's Medication Regimen Review dated 12/9/24, showed if clinically feasible, please provide a duration of therapy for the Preparation H rectal ointment. b. Review of Resident 17's Order Summary Report showed a physician's order dated 12/12/24, to administer Benadryl (antihistamine) 25 mg one tablet by mouth at bedtime for allergy/itching. Review Resident 17's Consultant Pharmacist's Medication Regimen Review dated 1/16/25, showed the resident currently had an order for Benadryl 25 mg at bedtime for allergy/itching. The MRR further showed first generation antihistamines, such as Benadryl, possessed more anticholinergic and sedative effects than the new agents. Consult with the physician if a change to a less sedating agent, such as Zyrtec (antihistamine), Allegra (antihistamine), or Claritin (antihistamine) would be feasible for Resident 17. Further review of Resident 17's medical record failed to show the facility had addressed the Pharmacy Consultant's recommendations for the Preparation H and Benadryl medications. On 3/5/25 at 1013 hours, an interview was conducted with the DON. When asked about the facility's process for reviewing and addressing the Pharmacy Consultant's MRR recommendations, the DON stated she handed the MRR binder directly to the licensed nurse who then followed through and notified the physician with the specific recommendation. The licensed nurse would then write done next to the recommendation once the recommendation was addressed. The DON verified when the recommendation was addressed with the physician, whether the physician approved the recommendations or not, the licensed should document in the resident's progress notes. On 3/6/25 at 0900 hours, a follow-up interview was conducted with the DON. The DON provided her progress note documentation dated 3/6/25 at 0827 hours, which showed the LVN called Resident 17's hospice regarding the Consultant's Pharmacist's recommendation for the Preparation H medication for December 2024. On 3/6/25 at 0925 hours, a follow-up interview was conducted with the DON. The DON provided LVN 2's progress note dated 3/5/25 at 1903 hours, which showed the hospice company providing services to Resdient 17 acknowledging the pharmacy recommendation for the Benadryl medication for January 2025. The DON verified the pharmacy recommendations were followed up after she was informed by the surveyor for the pharmacy recommendations for December 2024 and January 2025 were not done for Resident 17.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 11.11%. Two of two licensed nurses (LVNs 1 and 2) observed during the medication administration were found to have made an errors. * LVN 1 failed to reconstitute the polyethylene glycol medication as per the physician's order for Resident 8. LVN 1 reconstituted the polyethylene glycol medication with five oz of water instead of eight oz of water per the physician's order. * LVN 2 failed to reconstitute the polyethylene glycol medication as per the physician's order for Resident 3. LVN 2 reconstituted the polyethylene glycol medication with five oz of water instead of eight oz of water per the physician's order. In addition, LVN 2 failed to administer Resident 3's vitamin B12 (supplement) medication as ordered. These failures had the potential to negatively affect the residents' health conditions and posed the risk for possible complications or delay in interventions. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with prescriber orders, including any required time frames. 1. On 3/4/25 at 0816 hours, a medication administration observation for Resident 8 was conducted with LVN 1. LVN 1 prepared and administered Resident 8's medications, which included the polyethylene glycol powder 17 gm. LVN 1 was observed reconstituting the polyethylene glycol powder medication with five oz of water and administered it to the resident. LVN 1 verified she mixed the polyethylene glycol powder medication in a plastic cup with five oz of water. The plastic cup showed five oz on the bottom of the cup. Review of Resident 8's Order Summary Report showed a physician's order dated 10/17/24, to administer polyethylene glycol 3350 powder 17 gm/scoop by mouth one time a day for bowel management, to mix with eight oz of water. On 3/4/25 at 0852 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated she reconstituted the polyethylene glycol medication in five oz of water because that was the size of the plastic cup. LVN 1 verified Resident 8's physician's order for the polyethylene glycol medication showed to mix the medication with eight oz of water. 2. On 3/4/25 at 0919 hours, a medication administration observation for Resident 3 was conducted with LVN 2. LVN 2 prepared and administered Resident 3's medications, which included the polyethylene glycol powder 17 gm. LVN 2 was observed reconstituting the polyethylene glycol powder medication in five oz of water and administered it to the resident. LVN 2 verified she mixed the polyethylene glycol medication in a plastic cup with five oz of water. Review of Resident 3's Order Summary Report showed the following physician's orders: - dated 6/30/24, to administer polyethylene glycol 3350 powder 17 gm/scoop by mouth one time a day for bowel management, to mix with eight oz of water. - dated 9/11/24, to administer vitamin B12 100 mcg one tablet by mouth one time a day for supplement. Review of Resident 3's MAR for March 2025 showed the vitamin B12 medication was administered on 3/4/24 at 0900 hours, along with the other medications. However, during the medication administration observation with LVN 2, LVN 2 was not observed preparing and administering the vitamin B12 to Resident 3. On 3/4/25 at 1015 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified she did not administer the vitamin B12 medication to Resident 3 during the medication administration observation. LVN 2 verified she signed Resident 3's MAR for the vitamin B12 as administered on 3/4/25, along with the medications she administered during the medication administration observation. LVN 2 stated the medication was not availiable in the medication cart. In addition, LVN 2 verified Resident 3's physician's order for the polyethylene glycol medication showed to mix the medication in eight oz of water. On 3/5/25 at 0815 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure two of three final sampled residents (Residents 1 and 13) reviewed for hospice services received the necessary care and services. * The facility failed to ensure the hospice visit calendar was available in Resident 1's medical record and provide accurate documentation of the hospice staff visits for Resident 1. The facility also failed to ensure the care plan were updated and available in the resident's medical record. * The facility failed to ensure the hospice visit calendar was available in Resident 13's medical record. Additionally, the facility failed to ensure a care plan was initiated for the hospice services provided for Resident 13. These failures posed a risk of delayed communication and the provision of hospice care between the hospice provider and the facility. Findings: Review of the facility's P&P titled Hospice Program dated 7/2017 showed the facility has designated the DON to coordinate care provided to the resident by our facility staff and the hospice staff. She is responsible for the following: - Obtaining the following information from the hospice: the most recent hospice plan of care specific to each resident, hospice election form, physician certification and recertification of the terminal illness specific to each resident. - Ensuring that the facility staff provided orientation on the policies and procedures of the facility including the resident rights, appropriate form and record keeping requirements, to hospice staff furnishing care to the residents. The P&P also showed the coordinated care plans for the residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by our facility (including the responsible provider and discipline assigned to specific tasks) in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Medical record review for Resident 1 was initiated on 3/3/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report dated 3/4/25, showed a physician's order dated 8/28/24, to admit Resident 1 to the facility under Hospice Provider A. a. Review of Resident 1's hospice binder did not show a calendar to indicate when the hospice staff would visit the resident for January, February, and March 2025. On 3/4/25 at 0930 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked about the licensed nurse, social worker, and HA visits for January, February, and March 2025. LVN 1 was unsure and verified the hospice visit calendar was not in Resident 1's medical record. On 3/5/25 at 1430 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 was also unsure about Resident 1's hospice visit frequencies for January, February, and March 2025. LVN 2 verified the above findings. b. Review of Resident 1's Order Summary Report dated 3/4/25, showed a physician's order dated 8/28/24, to have the skilled nursing visits twice per week and three PRN visits for symptom management or condition changes. The HA visits were ordered twice per week for personal hygiene, ADL care, and ROM exercises. Review of the facility document titled CHHA Communication Sheet for January and February 2025 did not show the documented HA visit entries as ordered twice a week. Further review of the communication sheet showed documented entries on 1/30, 2/4, 2/26, and 2/28/25. On 3/5/25 at 1400 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DSD/IP. The DSD/IP was asked about the CHHA Communication Sheet for January, February, and March 2025. The DSD/IP was unable to provide the documentation to show the HA documented visits. The DSD/IP stated the HA should have documented their visits twice per week. The DSD/IP verified the above findings and stated Hospice Provider A's plan of care was followed. c. Review of Resident 1's hospice binder showed a physician's certification for hospice benefits covering the period from 10/1 to 11/29/24. The most recent plan of care for hospice was dated October 2024. On 3/5/25 at 1400 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DSD/IP. The DSD/IP was asked to show the latest physician certification and plan of care for hospice for Resident 1. The DSD/IP stated the last physician certification for hospice was on 11/29/24, and the plan of care from Hospice Provider A dated October 2024 was available in the resident's medical record. However, review of Resident 1's medical record and hospice binder did not show for an updated physician certification for December 2024 to March 2025 and there was no current hospice care plan. The DSD/IP stated the facility's care plan should have been updated to include the hospice visits from the skilled nursing hospice staff, social worker, HA, and other hospice staff. The DSD/IP verified the above findings. 2. Medical record review for Resident 13 was initiated on 3/3/25. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's H&P examination dated 2/20/25, showed Resident 13 had a diagnosis of Alzheimer's disease and had the capacity to understand and make decisions. Review of Resident 13's Order Summary Report for March 2025 showed a physician's order dated 2/20/25, to admit the resident to Hospice Provider A on routine level of care with a primary diagnosis of Alzheimer's disease. Review of the Resident 13's hospice binder did not show a calendar for January February, and March 2025 to show the schedule when the hospice staff were visiting Resident 13. Review of Resident 13's plan of care failed to show a care plan problem addressing Resident 13's hospice care services (focuses on improving the quality of life for individuals with terminal illnesses and their families by providing comfort, pain management, and emotional and spiritual support, rather than focusing on curing the disease). On 3/6/25 at 1117 hours, an interview and concurrent medical record review was conducted with the DSD/IP. The DSD/IP was informed and acknowledged the above findings. The DSD/IP stated there should be a care plan to ensure the facility staff were aware of Resident 13's plan of care while receiving hospice care services. On 3/6/25 at 1529 hours, a follow-up interview and concurrent medical record review was conducted with the DSD/IP. The DSD/IP stated there should be a calendar in placed to ensure the facility staff were aware when the hospice staff were scheduled to visit the resident and to provide the hospice staff an update of Resident 13's condition.

CONCERN (D)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

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Based on interview, facility document review, and facility P&P review, the facility failed to ensure the QAPI committee developed and implemented action plans to include monitoring the effectiveness of those plans in achieving and sustaining the improvement for a repeated deficient practice cited at F756. This was not in accordance with the facility's POC from the last recertification survey completed on 3/14/24. This failure had the potential to affect the quality of care for all the residents in the facility. Findings: Review of the facility's P&P titled Quality Assurance and Performance Review dated 2/2020 showed the QAPI plan describes the process for identifying and correcting quality deficiencies. Key components of this process include: - Tracking and measuring performance; - Establishing goals and thresholds for performance measurement; - Identifying and prioritizing quality deficiencies; - Systematically analyzing underlying causes of systemic quality deficiencies; - Developing and implementing corrective action or performance improvement activities; and - Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. Review of the POC submitted by the facility to the CDPH, L&C Program for F756 cited from the last recertification survey completed on 3/14/24, showed the DON and/or a designee would be responsible and accountable to perform routine weekly audits of the pharmacy consultant recommendations to ensure the recommendations are completed on a monthly basis. On 7/16/18 at 1130 hours, an interview was conducted with the Administrator and DON. The DON was asked about the improvement action for the DRR cited in the previous recertification survey. The DON stated she should have assigned the charge nurse to review and address the DRR but forgot to do so. The DON stated she placed the DRR in the binder but should have assigned and given the DRR to the licensed nurse to ensure the DRR was followed up and communicated to the physician. The DON verified the above findings. Cross reference to F756.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility document review, the facility failed to ensure the essential equipment was maintained in safe operating condition. * The facility failed to ensure the quality control record for February and March 2025 reflected on the glucometer with the serial number 1040-4333929. This failure had the potential for the residents requiring glucose checks to have inaccurate readings. Findings: On 3/4/25 at 1339 hours, a concurrent review of the Assure Platinum Blood Glucose Monitoring System: Quality Control Record for February and March 2025 and inspection of the glucometer with the serial number 1040-4333929 was conducted with LVN 1. The log showed the glucometer quality control was completed for February and March 2025. However, when the glucose quality control results documented on the log were compared to the glucometer device's saved results (memory), it showed the glucose quality control results documented for 2/1 through 2/4, 2/6, 2/8 through 2/13, 2/16 through 2/20, 2/23 through 2/27, and 3/3/25, were not observed on the glucometer device. For example, the documented normal control result of 96 mg/dl and the high control result of 256 mg/dl documented on the log on 2/1/25, were not observed on the glucometer device. LVN 1 verified the above findings. On 3/5/25 at 0815 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review for Resident 1 was initiated on 3/3/25. Resident 1 was admitted to the facility on [DATE]. Review of the facility's bed measurement list showed Resident 1's bed was measured; however, the height measurement of the mattress was inaccurate. On 3/6/25 at 1402 hours, an observation, interview, and concurrent facility document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified there was a discrepancy between the actual measurements and bed inspection measurements. Cross reference to F700, example #4. 3. On 3/4/25 at 0945 and 1212 hours, Resident 12 was observed in bed with the bilateral one-half upper side rails raised. Review of the facility's bed measurement list showed Resident 12's bed was measured; however, the height of the mattress was inaccurately measured. Cross reference to F700, example #3. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' entrapment assessments were accurately completed for four of 12 final sampled residents (Residents 1, 12, 13, and 20). This failure had the potential to negatively impact the residents, resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Proper Use of Side Rails revised date 12/2016 showed an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: - Bed mobility; - Ability to change positions, transfer to and from bed or chair, and to stand and toilet; - Risk of entrapment from the use of side rails; and - That the bed's dimensions are appropriate for the resident's size and weight. Review of the facility's Bed Inspection Measurements dated 1/6/25, showed the bed numbers 13, 18, 19, and 26 were measured; however, the measurements for the bedframe lengths, mattress lengths, mattress heights, and zones pass or fail assessments were inaccurate. 1. On 3/3/25 at 0907 hours, during the initial tour of the facility, Resident 13 was asleep in bed with the bilateral half side rails elevated at the head of the bed. On 3/4/25 at 0836 hours, Resident 13 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 13 was initiated on 3/3/25. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 13's plan of care showed a care plan intervention dated 12/16/24, to use the bilateral half side rails to maximize independence with turning and repositioning in bed. Review of Resident 13's H&P examination dated 2/20/25, showed Resident 13 had a diagnosis of Alzheimer's disease and had the capacity to understand and make decisions. Cross reference to F700, example #1. 2. On 3/3/25 at 0934 hours and 3/4/25 at 0851 hours, Resident 20 was observed lying in bed with the bilateral half side rails elevated at the head of the bed. Medical record review for Resident 20 was initiated on 3/3/25. Resident 20 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 20's Order Summary Report for March 2025 showed a physician's order dated 8/21/24, to apply the bilateral upper side rails while in bed for increased bed mobility and repositioning. Review of Resident 20's H&P examination dated 8/22/24, showed Resident 20 had the capacity to understand and make decisions. On 3/6/25 at 1402 hours, an observation, interview, and concurrent facility document review was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified there were discrepancies between the actual bed measurements, assessments of the zones, and bed inspection measurements. On 3/6/25 at 1448 hours, an interview and concurrent facility document review was conducted with the Administrator. The Administrator acknowledged the discrepancies between the actual bed measurements, assessment of the zones and the bed inspection measurements and stated the resident beds should have been measured accurately for safety reasons and to prevent the potential for entrapment. Cross reference to F700, example #2.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the microwave utilized to warm up the food was maintained in sanitary condition and free of food residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the cutting board was kept in a sanitary condition and with cleanable surface. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the foods prepared in the facility's kitchen. Findings: Review of the facility's Diet Type Report dated 3/3/25, showed 23 of 23 residents consumed the foods prepared in the kitchen. 1. Review of the facility's P&P titled Sanitation dated 2023 showed all the 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. According to the USDA Food Code 2022 Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The kitchen microwave on a countertop shelf was observed to be dirty with white crumbs on the glass plate inside the microwave. The [NAME] verified the findings. 2. Review of the facility's P&P titled Hoods, Filters, and Vents dated 2023 showed the hoods must be cleaned every two weeks and must be free of dust and grease. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The kitchen hood over the stove had black, dirt residue. The [NAME] acknowledged the findings and stated the dietary staff cleaned the hood once a week on Wednesdays and the hood was also cleaned by an outside company. The sticker on the hood showed it was last serviced on 10/2024. 3. Review of the facility's P&P titled Sanitation dated 2023 showed all the 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. Plastic ware, china, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. Plastic ware is bleached as necessary to prevent staining. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, (A) Utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The following was observed and verified by the Cook: - Two slotted scoops with black handles partially melted. - Two scoops with black handles partially melted. - One rubber spatula with red handle had chipped and cracked edges. - Two stainless steel spatulas with discolored and partially melted handles. - One stainless steel slotted spoon discolored with fuzzy film. - One stainless steel tong with black rubber handle partially melted and worn out. - One basting brush for butter had frayed bristles and worn out. - One white plastic cheese grater worn out with cracked, chipped, and broken edges. - Four stainless steel whisk with chipped and cracked rubber handles. The [NAME] acknowledged the above findings and stated the above items should have been replaced for infection control purposes. 4. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-602.13, Nonfood- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The following was observed and verified by the Cook: - Two scoops with black handles had dry water spots. - One scoop with cream handle had fuzzy film and dry white crusted residue. - Two scoops with blue handles had dry crusted residue. - One scoop with white handle use for food portioning had fuzzy film. - One scoop with green handle use for food portioning had dry crusted residue and fuzzy film. - One scoop with blue handle use for food portioning had dry crusted residue and fuzzy film. - One mesh strainer had dry crusted residue. The [NAME] verified the above findings and stated all the dirty utensils should have been washed to prevent cross contamination. 5. According to the USDA Food Code 2022 Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 3/3/25 at 0757 hours, during the initial kitchen tour, a concurrent observation and interview was conducted with the Cook. The light brown, green, red, and yellow cutting boards were observed fuzzy, heavily marred and had deep groves. The [NAME] verified the findings and stated the cutting boards should have been changed and the facility had new ones to replace them. On 3/5/25 at 1614 hours, an interview was conducted with the Dietary Supervisor. The Dietary Supervisor acknowledged all the above findings and stated the following: - All the dirty utensils should have been sanitized to prevent the growth of bacteria and for infection control purposes. - The microwave should have been cleaned for infection control purposes. - The chipped spatula should not be used because particles could fall and mixed in to the food. - The basting brush should have been replaced to prevent the bristles from getting mixed with the food. - The cutting boards were changed every three months and should have been replaced to prevent bacteria growth when not properly washed. - The mesh strainer should have been washed properly for infection control purposes. - The cheese grater should have been discarded and not used. - The whisk should have been replaced. - The hood over the stove was cleaned every six months and it was important to keep it clean to prevent dirt and grease from getting mixed with the food.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Medical record review of Resident 7 was initiated on 3/3/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 7's Order Summary Report dated 3/1/25, showed a physician's order dated 2/18/25, to place the resident on the EBP due to an indwelling urinary catheter. On 3/3/25 at 0830 hours, CNA 3 was observed assisting Resident 7 and handing a wet towel to the resident to wipe the resident's forehead and face. CNA 3 was observed not wearing a gown. In front of the resident's room door, a signage was observed indicating EBP and for the facility staff to wear a gown and gloves when providing direct care to the resident. On 3/4/25 at 0805 hours, CNA 3 was observed touching and repositioning Resident 7, and picking up Resident 7's urinary catheter bag, without wearing a gown. On 3/4/25 at 0830 hours, an interview was conducted with CNA 3. CNA 3 was informed of the above observations when she was providing care to Resident 7 without wearing a gown. CNA 3 stated she knew she needed to wear a gown but forgot to because she was rushing to assist the resident. CNA 3 verified the findings. On 3/4/25 at 0900 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above findings and stated CNA 3 should have worn a gown and gloves in accordance with the EBP. LVN 1 verified Resident 7 had the EBP due to the presence of indwelling urinary catheter. Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were followed and implemented as evidenced by: * Residents 2, 6, 9, 18, and 22's physicians were not notified when the residents' infections did not meet the McGeer's criteria. * The facility failed to ensure Resident 627 had contact isolation precautions in place due to the clostridium difficile infection. * The Infection & Control Surveillance Log of Infections for February 2025 was inaccurate. Resident 627's CAI infection was not included in the log. * The blood pressure wrist machine used for the residents did not have a cleanable surface (Velcro with cloth material). * The facility failed to ensure the hospice licensed staff practiced EBP when providing wound care treatment for Resident 20 who was on the EBP. * CNA 3 did not wear gown when provided dressing and hygiene to Resident 7 who was on the EBP. These failures posed the risk of transmitting infections and not accurately tracking the infections and appropriate antibiotic use. Findings: 1. On 3/5/25 at 0923 hours, an interview, medical record review, and concurrent facility document review of the facility's Infection Control Program was conducted with the DSD/IP. a. Review of the facility's Infection Surveillance Monthly Report for January 2025 was conducted with the DSD/IP. The DSD/IP stated the report was used to track and report about the infections for January 2025. The DSD/IP verified the report failed to show how many residents did not meet the McGeer's criteria. Further review of the Infection Surveillance Monthly Report for January 2025 with the DSD/IP showed Residents 9, 18, and 22's physicians were not notified the residents' infections did not meet the McGeer's criteria. b. When asked about the total CAIs in the facility, the DSD/ IP stated there were a total of two CAIs. However, during review of the facility's Infection & Control Surveillance Log for February 2025 with the DSD/IP, the DSD/IP verified the log failed to include Resident 627's infection. Further review of Resident 627's medical record with the DSD/IP showed Resident 627 was readmitted to the facility on [DATE], with a diagnoses of clostridium difficile infection. The DSD/IP stated Resident 627 was to have contact isolation precautions in place. The DSD/IP verified Resident 627 did not have a signage outside of her room to indicate the resident was on contact isolation precautions. Review of Resident 627's bowel elimination documentation with the DSD/IP showed Resident 627 had a total of 10 loose/diarrhea episodes in February 2025 and a total of five loose/diarrhea episodes in March 2025. The DSD/IP stated the CNAs were inaccurately documenting Resident 627's bowel movements. The DSD/IP acknowledged Resident 627's clostridium difficile infection should have been documented in the February 2025 Infection & Control Surveillance Log. Further review of the February 2025 Infection & Control Surveillance Log with the DSD/IP showed Residents 2 and 6's physicians were not notified when the residents' infections did not meet the McGeer's criteria. 3. According to the CDC, enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for the residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition. Review of the facility's signage for Enhanced Barrier Precautions showed everyone must clean their hands, including before entering and when leaving the room. It also showed the providers and facility staff must wear gloves and gown for the following high-contact resident care activities: dressing, bathing/ showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, and wound care: any skin opening requiring a dressing. Review of the facility's P&P titled Enhanced Barrier Precautions dated 8/2022 showed Enhanced barrier precautions are used as an infection prevention and control intervention to reduce the spread of MDROs to the residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/ or indwelling medical devices regardless of MDRO colonization. Medical record review for Resident 20 was initiated on 3/3/25. Resident 20 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 20's H&P examination dated 8/22/24, showed Resident 20 had the capacity to understand and make decisions. Review of Resident 20's plan of care showed a care plan problem addressing Resident 20's enhanced barrier precautions due to bilateral lower extremity open wound. An intervention dated 2/20/25, included to utilize PPE (gown, gloves, face shield as indicated) during high contact resident care activities. On 3/3/25 at 1209 hours, Resident 20's room was observed with an enhanced barrier precaution signage posted by the door. The Hospice LVN was observed standing by the foot of the bed of Resident 20 and rendering wound care treatment. The Hospice LVN was observed wearing gloves but not wearing a gown. On 3/3/25 at 1211 hours, an interview was conducted with the Hospice LVN. The Hospice LVN verified the above findings. The Hospice LVN verified there was a signage by Resident 20's door showing Resident 20 was on the EBP. The Hospice LVN stated she missed the sign and should have worn a gown to prevent cross contamination. On 3/3/25 at 1220 hours, LVN 1 was informed of the above findings and stated the EBP signage was used to identify any open wound and the hospice staff should have worn the proper PPE for infection control purposes. On 3/6/25 at 1013 hours, an interview was conducted with the DSD/IP. The DSD/IP acknowledged the above findings and stated the EBP included donning of gown, gloves, and mask for high contact activities such as wound care treatment to protect the resident from any MDRO and other infections. 2. Review of the facility's P&P titled Cleaning and Disinfection of Environmental Surfaces revised August 2019 showed all non-critical surfaces are to be disinfected with an EPA registered intermediate or low level hospital disinfectant according to the labels safety precautions and use directions. Review of the Medline Micro-Kill Two germicidal wipes manufacturer guidelines showed the wipes are used on hard, non-porous surfaces and equipment made of stainless steel, plastic, Formica (laminate material made of paper and synthetic resins) and glass. On 3/4/25 at 0816 hours, a medication administration observation was conducted with LVN 1 for Resident 8. LVN 1 was observed using a wrist BP cuff with Velcro and cloth material closure to assess Resident 8's BP. After obtaining the resident's BP reading, LVN 1 used the Micro-Kill wipes to disinfect the wrist BP cuff before using it for the next resident. On 3/4/25 at 0919 hours, a medication administration observation was conducted with LVN 2 for Resident 3. LVN 2 was observed using a wrist BP cuff with Velcro and cloth material closure to assess Resident 3's BP. LVN 2 then used the Micro-Kill wipes to disinfect the wrist BP cuff. On 3/4/25 at 1015 hours, an interview was conducted with LVN 2. LVN 2 verified the Micro-Kill wipes was only for non-porous surfaces and it was inappropriate to use on the porous material of the wrist BP cuff. On 3/4/25 at 1025 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the wrist BP cuff had a cloth fabric material. LVN 1 was informed and acknowledged the Micro-Kill wipes manufacturer's guideline showed to use the wipes for hard, non-porous surface. LVN 1 verified the disinfectant wipes were not appropriate to disinfect the Velcro/cloth material on the BP cuff. LVN 1 stated the facility had an electronic BP machine, manual BP cuffs, and stethoscopes for the facility staff to use, which had a cleanable surfaces and materials. LVN 1 acknowledged the equipments with non cleanable materials was an infection control issue.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0578 (Tag F0578)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview, medical record review, and facility P&P review, the facility failed to ensure the POLST was updated and the copy of advance directive form was obtained for one of 12 final sampled residents (Resident 1). This failure had the potential for the resident's decisions regarding their healthcare and treatment not being honored. Findings: Medical record review for Resident 1 was initiated on 3/3/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's POLST dated 8/2/24, showed the resident had no advance directive. Review of Resident 1's Advance Directive Acknowledgement form dated 8/5/24, showed the resident's family had executed an advance directive. However, review of Resident 1's medical record failed to show the copy of the resident's advance directive. On 3/4/24 at 1000 hours, an interview and concurrent medical record review was conducted with LVN 1 and the Social Services/Activities Director. When asked if Resident 1's family would like to execute an advance directive, both LVN 1 and the Social Services/Activities Director stated the resident's family member had executed an advance directive. When asked why the resident's POLST did not reflect the advance directive, the Social Services/Activities Director stated the POLST should have been updated because the resident's family member had executed an advanced directive. The Social Services/Activities Director further stated the facility did not follow up with Resident 1's family member to obtain a copy of the resident's advance directive. The Social Services/Activities Director stated she would contact the resident's family member to obtain a copy of Resident 1's advanced directive. The Social Services/Activities Director verified the above findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Transfer Notice (Tag F0623)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 26 was initiated on 3/3/25. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Notice of Transfer/discharge date d 1/5/25, showed under the section for sending a copy to the LTC Ombudsman office was left blank. Review of Resident 26's progress notes dated 1/5/25, showed Resident 26 was discharged to home. On 3/5/25 at 1120 hours, an interview and concurrent medical record review was conducted with the Social Services/Activities Director. When asked if the facility had sent a copy of the Notice of Transfer/Discharge to the LTC Ombudsman for the resident's discharge, the Social Services/Activities Director verified the facility had not sent the notice. The Social Services/Activities Director was unable to provide documentation to show the LTC Ombudsman was notified about the resident's discharge. The Social Services/Activities Director verified the findings. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to notify the resident and/or their representative of the transfer and reason for the transfer in writing and send a copy of the Notice of Transfer/Discharge to the LTC Ombudsman for two of three closed record sampled residents (Residents 21 and 26). These failures posed the risk for the resident and/or their representative of not knowing about the appeal process and posed the risk of the LTC Ombudsman not being aware of the circumstances of the residents' transfer/discharge should an appeal be filed or requested by the resident or their representatives regarding the transfer. Findings: Review of the facility's P&P titled Transfer and Discharge revised 12/2016 showed the facility will provide written notices for emergency transfers to the resident or resident's representative and the Ombudsman. These may be sent when practicable but need to be sent before transfer or discharge. Medical record review for Resident 21 was initiated on 3/6/25. Resident 21 was admitted to the facility on [DATE], and transferred to the acute care hospital on 2/17/25. Review of Resident 21's Transfer/discharge date d 2/17/25, showed the reason for the transfer was due to possible G-tube infection or dislodgement. However, further review of Resident 21's medical record failed to show documented evidience the resident and/or their representative was provided a written notification of the transfer and reason for the transfer. In addition, there was no documented evidence to show a copy of the notice of transfer was sent to the LTC Ombudsman. On 3/6/25 at 1055 hours, an interview and concurrent medical record review was conducted with the Office Manager. The Office Manager verified the above findings and stated the facility did not send the written notices for the acute care hospital transfers. The Office Manager was unable to provide documentation to show the written notice of transfser was provided to the resident, resident's representative, and LTC Ombudsman. On 3/6/25 at 1056 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 acknowledged the above findings and stated the facility did not send the written notices for the acute care hospital transfers. LVN 1 was unable to show any documentation of the written notice of transfer to either the resident, his representative or the LTC Ombudsman.

MINOR (B)

Minor Issue - procedural, no safety impact

MDS Data Transmission (Tag F0640)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDS for discharge was completed and transmitted for one of 12 sampled residents (Resident 12). This failure had the potential for not having current information in the resident's medical record. Findings: Medical record review for Resident 12 was initiated on 3/5/25. Resident 12 was readmitted to the facility on [DATE]. Review of Resident 12's progress note dated 10/15/24, showed Resident 12 was transferred and admitted to the acute care hospital. Review of Resident 12's admission Record dated 2/9/24, showed Resident 12's most recent acute care hospital stay was between 10/14 to 10/18/24. Review of Resident 12's list of transmitted MDS assessment failed to show the MDS was completed to reflect Resident 12's October 2024 discharge from the facility. On 3/4/25 at 1359 hours, an interview was conducted with the Administrator. The Administrator was informed and verified the above findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to accurately code the MDS related to RNA services for one of 12 final sampled residents (Resident 10). This failure posed a risk of the resident not receiving an individualized care plan tailored to their specific needs. Findings: Medical record review for Resident 10 was initiated on 3/3/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's MDS quarterly assessment dated [DATE] and 2/5/25, showed Section O for Restorative Nursing Program (range of motion - passive and active) was left blank. Review of Resident 10's Order Summary Report dated 3/4/25, showed the following physician's orders dated 9/4/24, for RNA: - The resident may wear a left knee orthosis and bilateral PRAFO for up to six hours, five times per week, for 90 days, as tolerated. Re-evaluation was scheduled for 11/21/24. - The resident may wear bilateral PRAFO on both ankles daily, five times per week, for up to six hours, as tolerated, for 90 days. Re-evaluation was also scheduled for 11/21/24. - Active assist and passive range of motion (AA/PROM) exercises were to be provided to all extremities daily, five times per week, for 90 days. Re-evaluation was scheduled for 11/21/24. On 3/6/25 at 0945 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. When asked about Resident 10's MDS assessment, Section O for the Restorative Nursing Program, the MDS Coordinator stated she could not locate the RNA program on the EHR for Resident 10. The MDS Coordinator further stated she did not have a computer access to view the RNA program in the EHR for Resident 10, which was the reason why the RNA was not coded in the resident's MDS for 11/5/24 and 2/5/25. On 3/6/25 at 1400 hours, an interview and concurrent medical record review was conducted with the DSD/IP. The DSD/IP stated Resident 10 had been receiving RNA services, including active assist and passive range of motion exercises since September 2024. The DSD/IP acknowledged and verified Resident 10's MDS was inaccurate.

Apr 2024 1 deficiency

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0657 (Tag F0657)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan for one of three sampled residents (Resident 1) was revised after Resident 1 had reported an abuse allegation against CNA 1. This failure put Resident 1 at risk of not receiving resident-centered care. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The P&P showed the comprehensive, person-centered care plan will include the following: a. measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; g. incorporates identified problem areas; h. incorporates risk factors associated with identified problems; k. reflects treatment goals, timetables and objectives in measurable outcomes; Medical record review for Resident 1 was initiated on 4/19/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Five-Day MDS dated [DATE], showed Resident 1 with a BIMS score of 9 (according to the MDS RAI Manual, a score of 8-12 indicates the resident's cognition is moderately impaired). Further review of the medical record showed Resident 1 had an allegation of CNA 1 pushing her off the shower chair and putting the hand around her throat. However, review of Resident 1's care plan showed no documented evidence of the revised care plan related to Resident 1's reported abuse allegation. On 4/19/24 at 1416 hours, a concurrent interview and medical record review with LVN 1 was conducted. LVN 1 confirmed Resident 1 did not have a new or revised care plan to address the alleged abuse incident by CNA 1. LVN 1 stated the care plans were an important part of the resident's care and there should be a care plan for the abuse allegation. On 4/19/24 at 1456 hours, a concurrent interview and medical record review with the DON and DSD was conducted. The DON and DSD verified no care plan was created or updated for the abuse allegation incident between Resident 1 and CNA 1 on the day of the incident. The DON further stated the resident's care plans provided interventions on how the facility staff could care for the residents. The DON further stated the care plans were a guide for the resident's care. On 4/23/24 at 1240 hours, an interview with the Administrator and DON was conducted. The Administrator and DON acknowledged the above findings.

Mar 2024 21 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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2. Review of the facility's P&P titled Call System dated 9/2022 showed the residents are provided with a means to call the staff through a communication system that directly calls a staff member or a centralized work station. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. On 3/13/24 at 0835 hours, Resident 130 was observed in bed sleeping with both eyes closed with the upper right side rail and middle left side rail up. The resident's call light was observed on the floor toward the middle part of the bed. On 3/13/24 at 0837 hours, the above findings were verified with RNA 1. RNA 1 stated the resident should have the call light within reach at all times to ensure the assistance was provided when needed. On 3/13/24 at 0910 hours, Resident 130 was observed lying in bed watching TV. The call light was observed hanging down from the bed rail. When asked about the call light, Resident 130 stated he preferred to have it within reach at all times. He further stated he felt safer when he could call for help by pressing the call light button. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodation to meet the needs for one of 14 final sampled residents (Resident 130) and one nonsampled resident (Resident 25). * The facility failed to ensure the call lights for Residents 25 and 130 were within the resident's reach. This failure had the potential to negatively impact the resident's physical and psychosocial well-being or would result in delayed provision of care. Findings: Review of the facility's P&P titled Call System, Resident dated 9/22 showed each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor. 1. During the initial tour of the facility on 3/11/24 at 0850 hours, Resident 25 was observed lying in bed. The call light was observed to be wrapped around the bed's side rail and on the floor. On 3/11/24 at 0900 hours, a concurrent observation and interview with Resident 25 was conducted with CNA 1 in Resident 25's room. Resident 25's call light was observed to be wrapped around the bed's side rail and on the floor. CNA 1 stated Resident 25 needed help from two CNAs to get up. Resident 25 stated she used the call light to call for help. CNA 1 observed the call light on the floor then moved the call light next to Resident 25. CNA 1 stated the call light was wrapped around the side rail and verified Resident 25 used the call light and the call light was not within her reach. On 3/14/24 at 1702 hours, the Administrator, DON, and QA/IP were informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 12 was initiated on 3/11/24. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 12's responsible party was listed as self. Review of Resident 12's H&P Examination dated 11/5/23 and 3/10/24, showed Resident 12 did not have the capacity to understand and make decisions and Resident 12's surrogate decisionmaker was the resident's daughter. Review of Resident 12's Physician Orders for Life-Sustaining Treatment (POLST) dated 11/3/23, showed a signature by Resident 12 under Section D, signature of patient or legally recognized decisionmaker. Review of the Advance Directive Acknowledgement form dated 11/3/23, showed Resident 12's acknowledgement of information regarding an Advance Directive. The form showed two areas for signature, one for resident with decision making capacity and another for resident without decision making capacity. However, Resident 12's signature was under option for the resident with decision making capacity. Review of the Consent to Treat dated 11/3/23 and 3/11/24, showed Resident 12's responsible party was herself and had signed the Consent to Treat forms. On 3/12/24 at 0910 to 0917 hours, an interview and concurrent record review was conducted with the SSD/AD and Business Office Manager. The SSD/AD stated Resident 12's responsible party was herself. The SSD/AD was asked how the responsible party was determined. The SSD/AD stated it would be if the person had the capacity to make decisions, they could be the responsible party if he/she wished to. The SSD/AD stated the capacity would be based on the H&P examination. The SSD/AD and Business Office Manager were informed and verified the POLST and consents should have been updated to be signed by Resident 12's responsible party. Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary timely assistance with the execution of an advance directive for healthcare and failed to ensure the POLST and Advance directive acknowledgement form was obtained for two of 14 final sampled residents (Residents 12 and 18). * Resident 18 was admitted to the facility on [DATE] and she informed the facility on 1/16/24, that she wished to execute an advance directive for health care. The facility attempted to contact the Ombudsman on 1/19/24, to schedule a time in which the Ombudsman could sign Resident 18's advance directive; however, the facility failed to follow up with the Ombudsman and Resident 18 had yet to formulate an advance directive. * The facility failed to ensure the POLST and Advance directive acknowledgement form were obtained from Resident 12's responsible party. These failures had the potential for the residents' decisions regarding their healthcare and treatment options to not be honored. Findings: Review of the facility's P&P titled Advance Directives revised 12/2016 showed if the resident indicates that she has not established advance directives, the facility staff will offer assistance in establishing advance directives. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 1. Medical record review for Resident 18 was initiated on 3/11/24. Resident 18 was admitted to the facility on [DATE]. Review of Resident 18's H&P examination dated 1/12/24, showed Resident 18 had the capacity to understand and make decisions. Review of Resident 18's Advance Directive Acknowledgement dated 1/16/24, showed Resident 18 had not executed an advance directive, and wished to execute an advance directive. Review of Resident 18's Social Services Note dated 1/19/24 at 1230 hours, showed Resident 18's family member (Family Member 1) was given information regarding the advance directive for healthcare. The SSD/AD documented she reached out to the Ombudsman for the schedule, to schedule a time to come to the facility to sign (the advance directive). The SSD/AD documented she was waiting for the Ombudsman's reply. On 3/12/24 at 0910 hours, an interview was conducted with Resident 18. Resident 18 stated she had yet to formulate an advance directive for health care. Resident 18 stated she wished to have Family Member 1 act as her power of attorney specific to health care decisions. On 3/12/24 at 0937 hours, an interview and concurrent medical record review was conducted with the SSD/AD. The SSD/AD verified Resident 18's Advance Directive Acknowledgement dated 1/16/24, showed Resident 18 had not executed an advance directive and Resident 18 wished to execute an advance directive. The SSD/AD verified she documented in her Social Services Note dated 1/19/24 1230 hours, that she provided Family Member 1 with information specific to advance directive for healthcare. The SSD/AD verified she reached out to Ombudsman (on 1/19/24) in an attempt to schedule a time in which the Ombudsman could come to the facility, to sign Resident 18's advance directive for healthcare; however, the SSD/AD was waiting for the Ombudsman to reply. Further review of Resident 18's medical record failed to show any documentation (after 1/19/24) specific to Resident 18 formulating an advance directive for healthcare. The SSD/AD verified the findings and stated she should have followed up with the Ombudsman within two weeks from her first attempt to contact the Ombudsman on 1/19/24, in order to facilitate Resident 18's request to formulate an advance directive for healthcare.

CONCERN (D)

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to obtain the physician's order for the discharge to home as well as documentation of the physician's notification upon leaving the facility for one of two closed medical records reviewed (Resident 28). This failure had the potential to affect the health and safety of the resident during the transition of care. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation last revised on 12/2016 showed the details of the transfer/discharge will be documented in the medical record and appropriate information will be communicated to the provider. On 3/13/24 at 0956 hours, closed medical record review was conducted for Resident 28 and showed Resident 28 was admitted to the facility for respite care from 12/10/23 to 1/3/24, and discharged home on 1/3/24. However, there was no physician's order for the resident's discharge in the closed medical record. Further review of Resident 28's Discharge summary dated [DATE], showed, Resident went home with wife on 1/3/24. Nurse reviewed medications with wife and returned all remaining medications and belongings at time of discharge. There was no documented evidence the physician was notified of the resident's discharge from the facility on 1/3/24. On 3/13/24 at 1057 hours, an interview conducted with DON. The DON verified there was no physician's order for th resident's discharge. The DON further stated a physician's order must be obtained for a safe discharge as well as ensuring the progress note showing the physician was notified at the time of discharge.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the manual titled Drive Med-Air Eight Inch Alternating Pressure Mattress Replacement System with Low Air Loss Manual revised 1/2/17, under the section Operation, showed the pump is preset in alternating mode and its cycle time is set at 10 min/60 Hz (the unit of frequency in the International System of Units (SI), equivalent to one event, or cycle per second) or 12 min/50 Hz. Press the Static button to set it in static mode, and the Static indicator will come on. NOTE! In static mode, the mattress provides a firm surface that makes it easier for the patient to transfer or reposition. The static mode prevents the patient from bottoming out when in a sitting position. Further review of the manual under the section Pressure Set Up, showed the users can easily adjust the air mattress to a desired firmness according to the patient's weight and comfort. Medical record review for Resident 19 was initiated on 3/11/24. Resident 19 was admitted to the facility on [DATE], and readmitted don 1/15/24. Review of Resident 19's MDS dated [DATE], showed Resident 19 was at risk for developing a pressure ulcers/injuries and admitted with two unstageable (not stageable due to coverage of wound bed by slough and/or eschar) pressure injuries/ulcers. Further review of the MDS showed Resident 19 was totally dependent for bed mobility to roll from left and right and from sit to lying. Review of Resident 19's Physician Orders for March 2024 showed an order dated 1/15/24, for LAL mattress for wound management. Review of Resident 19's plan of care showed a care plan problem initiated on 1/16/24, addressing Resident 19's risk for pressure injuries related to impaired skin integrity. The interventions included to provide pressure reducing surfaces on the bed and chair. Review of Resident 19's Weight Change History dated 3/14/24, showed on 3/7 and 3/12/24, Resident 19 weighted 108 pounds (lbs). On 3/11/24 at 0946 hours, Resident 19 was observed lying on a LAL mattress. The LAL mattress was turned on and set at 150 pounds and the static setting was on. On 3/11/24 at 1613 and 1630 hours, Resident 19 was observed lying in bed on a LAL mattress. The LAL mattress was turned on and set at 150 pounds and the static setting was on. The staff was not observed in Resident 19's room providing care. On 3/12/24 at 0753 hours, Resident 19 was observing lying in bed on a LAL mattress, positioned on his right side. The LAL mattress was turned on and set at 150 pounds and the static setting was on. On 3/12/24 at 0931 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 19 had multiple wounds and was on a special mattress. When asked about the settings for the LAL mattress, CNA 1 stated she did not know the settings on the LAL mattress and she did not touch the unit when providing care for Resident 19. On 3/12/24 at 1550 hours, an interview and concurrent observation of Resident 19 was conducted with LVN 2. LVN 2 stated Resident 19 had a LAL mattress to help relieve pressure while in bed. LVN 2 also stated she was unfamiliar with the LAL mattress unit or the settings. Concurrent observation of Resident 19's LAL mattress unit was conducted with LVN 2. LVN 2 verified the LAL mattress unit was set at 150 pounds for firmness and the static setting was on. When asked about Resident 19's current weight, LVN 2 stated Resident 19 weighed 108 pounds on 3/12/24. On 3/12/24 at 1615 hours, an interview and concurrent observation was conducted with the Hospice RN. The Hospice RN verified the firmness setting was set at 150 pounds and the static light was on. The Hospice RN stated she did not know what the LAL mattress setting should be. On 3/13/24 at 0810 hours, Resident 19 was observed lying on his back in bed on a LAL mattress. The LAL mattress was turned on and set at 350 pounds for firmness. On 3/13/24 at 0910 hours, a concurrent interview and medical record review was conducted with the DON. When asked about Resident 19's current weight, the DON stated Resident 19 weighed 104 pounds as of 3/1/24. When asked about the facility's role in the maintenance of the LAL mattress, the DON stated she expected the nurses to check the LAL mattress unit daily, to check that the unit was functioning and the settings were appropriate to the resident's weight. A concurrent observation of Resident 19's LAL mattress unit was conducted with the DON. The DON verified the setting for mattress firmness was set at 150 pounds, the DON was observed adjusting the dial to 100 pounds. Concurrent review of the Drive LAL Mattress manual was conducted with the DON. When asked about the Static setting, the DON stated in static mode, the mattress would be firm all the time. The DON was informed of the above findings and stated the purpose of the LAL mattress was to provide alternating pressure and aid in the prevention of pressure related issues. The DON further stated it should not have been on static mode. On 3/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development and worsening of pressure ulcers for two of 14 final sampled residents (Residents 16 and 19). * Resident 16 was evaluated to have blanchable redness to his left hip on 1/19/24. Resident 16 developed with DTI on the left hip on 2/11/24. The facility failed to ensure Resident 16's left hip was reassessed per the physician's order. The facility failed to provide the appropriate and necessary services to ensure Resident 16 did not develop a pressure ulcer in the facility. * The facility failed to ensure the LAL mattress setting was consistent with Resident 19's weight. These failures had the potential for the residents to develop the pressure ulcers or worsening of existing pressure ulcers. Findings: Review of the facility's P&P titled Prevention of Pressure Ulcers/Injuries revised 1/2017 showed to evaluate, report and document potential changes in the skin and review the interventions and strategies for effectiveness on an ongoing basis. Review of the National Pressure Injury Advisory Panel's (NPIAP) Clinical Practice Guideline titled Prevention and Treatment of Pressure Ulcers/Injuries dated 2019 showed maintaining skin integrity is essential in the prevention of pressure injures. The underlying cause and formation of pressure injuries is multifaceted; however, by definition, pressure injuries cannot form without loading, or pressure, on tissue. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues and, ultimately, in tissue damage. The NPIAP defines the pressure ulcer stages as follows: - Stage 3 pressure ulcer - full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling (damage to tissue beneath the skin surrounding the pressure ulcer). - Stage 4 pressure ulcer - full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. Often includes undermining and tunneling. - Unstageable pressure ulcer - full thickness tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. - Suspected Deep Tissue Injury (DTI) - intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. 1. Medical record review for Resident 16 was initiated on 3/11/24. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's MDS dated [DATE], showed Resident 16 had severe cognitive impairment and was dependent on the assistance of staff to roll to left and right. Review of Resident 16's Braden Risk Assessment Report dated 12/20/23, showed Resident 16 was at high risk for developing pressure injuries. Review of the Physician's Telephone Order dated 1/19/24, showed to cleanse with normal saline, pat dry to the left hip redness, apply skin barrier every shift for 14 days and evaluate. * Review of Resident 16's medical record failed to show a progress note or skin assessment completed regarding the change in Resident 16's skin on 1/19/24. * Further review of Resident 16's medical record showed Resident 16's skin was monitored for three days after the physician was notified of the left hip redness, however, there was no documented evidence a skin evaluation was completed 14 days after the physician's order on 1/19/24. Further review of the resident's medical record failed to show any additional assessment regarding Resident 16's left hip until 2/11/24. Review of Resident 16's Wound Assessment Report dated 2/11/24, showed Resident 16's skin was reevaluated to have a left hip DTI measuring 4 cm (length) x 4 cm (width) dark discoloration. The report also showed an order for treatment to cleanse with normal saline, pat dry, apply betadine and cover with dry dressing for 14 days. * Resident 16's medical record failed to show documented evidence of wound monitoring for Resident 16's left hip DTI was completed until 2/19/24. Review of Resident 16's General Nurses Note dated 2/19/24, showed Resident 16 with open DTI/unstageable to the left hip. The note also showed the following: - The physician was notified and wound consult was ordered. - Low air loss mattress to be delivered today. - The daughter was made aware. Review of Resident 16's Care Plan showed a care plan problem dated 11/30/23, to address Resident 16's risk for Pressure Ulcers; however, there was no revision or update to the care plan to address Resident 16's development of the DTI on 2/11/24. On 3/14/24 at 1100 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 stated Resident 16 was dependent for all bathing, toileting, and mobility. LVN 4 stated for change of condition, upon the physician's order, would do 72 hours monitoring and the treatment nurse would reassess the wound with the treatments. LVN 4 verified there was no progress note addressing Resident 16's change of condition on 1/19/24 or 2/11/24. On 3/14/24 at 1356 hours, a concurrent interview and medical record review was conducted with the DON and QA/IP Nurse. The DON and QA/IP Nurse were informed of the above findings. The QA/IP Nurse verified Resident 16's left hip redness was not reevaluated after 14 days as per the physician's order and verified there was no assessment completed until 2/11/24. The DON stated the charge nurse would be responsible for updating the care plan and verified there was no care plan initiated on 2/11/24, to address Resident 16's left hip DTI.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 8 was initiated on 3/13/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 12/7/23, showed the resident with a history of fall risk. Resident 8 required full assistance with the ADL care. Review of the physician's order dated 12/7/23, showed an order for a tab alarm in bed to alert the staff when getting up unassisted. Review of the care plan initiated on 12/9/23, for fall risk and prevention of falls failed to show the use of a tab alarm as ordered as one of the preventative measures to prevent falls. On 3/13/24 at 0827 hours, Resident 8 was observed lying in bed sleeping with the bilateral upper side rails up. The call light was within reach, but no tab alarm was attached as ordered. On 3/13/24 at 0835 hours, an interview was conducted with RNA 1. RNA 1 confirmed the findings and stated the resident had an order for a tab alarm in bed to alert the staff when the resident tried to get up without assistance. On 3/14/24 at 0925 hours, Resident 8 was observed lying in bed with HOB approximately 30 degrees. There was no tab alarm attached to the resident when in bed as ordered. On 3/14/24 at 0939 hours, an interview was conducted with CNA 3. The CNA confirmed Resident 8 had no tab alarm on when in bed. She further stated the resident should had a tab alarm in bed for safety purpose due to risk of falls. On 3/14/24 at 1050 hours, a concurrent interview and medical record review conducted with LVN 4. LVN 4 showed a physician's order for a tab alarm in bed initiated on 12/7/23. She further stated it was utilized for the residents with the fall risk. On 3/14/24 at 1115 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the order for the tab alarm in bed was not followed, with no informed consent and a care plan. When asked for a facility P&P related to the use of tab alarm, the DON stated there was no facility P&P for tab alarm usage at this time. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 22) and one nonsampled resident (Resident 8) remained free from accident hazards. * The facility failed to ensure CNA 1 locked the wheelchair brakes during a transfer for Resident 22 on 1/23/24, resulting in Resident 22 falling to the ground. * The facility failed to ensure the tab alarm was in place as per the physician's order for Resident 8. These failures had the potential to not prevent further falls for these rresidents. Findings: Review of the facility's P&P titled Falls and Fall Risk, Managing revised 3/2018 showed according to the MDS, a fall is defined as: Unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force. An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred. 1. Medical record review for Resident 22 was initiated on 3/11/24. Resident 22 was admitted to the facility on [DATE]. Review of Resident 22's H&P examination dated 7/17/23, showed Resident 22 could make her needs known but could not make medical decisions. Review of Resident 22's MDS dated [DATE], showed Resident 22 had moderately impaired cognition and required substantial/maximal assistance with transfers to and from a bed to a chair. Review of Resident 22's Physician Orders for March 2024 showed an order dated 8/7/22, may have a low bed with bedside floor mats. Review of Resident 22's plan of care showed an active care plan problem initiated on 7/30/22, addressing Resident 22's high risk for falls. The care plan showed Resident 22 had falls on 8/7 and 8/13/22. Review of Resident 22's General Nurse Note of a nursing entry dated 1/24/24 at 0716 hours, showed on 1/23/24 at 0930 hours, during the transfer from Resident 22's bed to the wheelchair by CNA 1, one of the brakes on the wheelchair was not locked and Resident 22 slipped to the floor. Resident 22 was assessed and administered Tylenol (analgesic) 323 mg two tablets for a pain level of 3 (on a 0-10 pain scale, with 0 = no pain and 10 = worst pain). Review of Resident 22's Post Fall assessment dated [DATE], showed the probable cause of fall was the wheelchair was not fully locked during assistance causing the wheelchair to move. Further review of the document showed the facility educated the CNA to ensure the wheelchair was fully locked when assisting the resident to/from the wheelchair. Review of Resident 22's IDT Incident Review dated 1/26/24, showed the IDT had conducted a post fall care conference and recommended to continue with the current plan of care. Additionally, the CNA was given an education regarding ensuring the wheelchair was locked during transfers. On 3/12/24 at 0940 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 22 required assistance with transfers from bed to wheelchair and back. CNA 1 stated Resident 22 had a recent fall in January 2024 when CNA 1 was assisting the resident to transfer from her bed to the wheelchair. CNA 1 stated during the assisted transfer to the wheelchair, Resident 22 grabbed the wheelchair handles and lost her balance, subsequently falling onto the bedside mat. On 3/14/24 at 0904 hours, an interview was conducted with the DON. The DON stated Resident 22 required one staff to assist during the transfers. The DON verified Resident 22 had a fall in January 2024 and the facility determined Resident 22's fall was related to staff failure to lock the wheelchair. The DON further stated the CNA was provided one on one in-service following the incident. On 03/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services related to GT for one of 14 final sampled residents (Resident 23). * The facility failed to ensure Resident 23's HOB was elevated during the enteral feeding to reduce the risk of aspiration. * The facility failed to ensure the licensed staff managed the GT feeding for Resident 23. RNA 1 was observed to turn off the GT feeding to assist with repositioning for Resident 23. These failures posed the risk for complications related to the use of GT for Resident 23. Findings: Review of the facility's P&P titled Enteral Feedings- Safety Precautions revised 11/2018 showed all personnel responsible for preparing, storing and administering enteral nutrition formulas will be trained, qualified and competent in his or her responsibilities. Under the section preventing aspiration showed to elevate the HOB at least 30 degrees during tube feedings. Medical record review for Resident 23 was initiated on 3/11/24. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's H&P examination dated 2/28/23, showed Resident 23 had a GT. Review of Resident 23's Physician Orders for March 2024 showed an order dated 4/12/23, to infuse Jevity 1.2 (enteral feeding formula) at 60 milliliters per hour (ml/hr) for 20 hours to provide 1200 ml/1440 kcal. a. Review of Resident 23's Physician Orders for March 2024 showed an order dated 2/21/23, for aspiration precaution, to elevate the HOB 30-45 degrees at all times during GT feeding. Review of Resident 23's plan of care showed an active care plan problem initiated on 10/5/22, addressing Resident 23's nutrition via GT. The care plan interventions included to maintain in an upright position during the GT feeding. On 3/11/24 at 1020 hours, Resident 23 was observed lying in bed with his legs hanging off of the right side of the bed. The GT feeding was observed infusing Jevity 1.2 at 60 ml/hr. CNA 1 was observed in Resident 23's room. CNA 1 stated Resident 23 needed to be repositioned. CNA 1 was then observed using the bed control to lower Resident 23's HOB. Resident 23's HOB was observed flat with the GT feeding still infusing. On 3/11/24 at 1024 hours, an interview was conducted with CNA 1. CNA 1 stated GT feedings should not be infusing when the resident was lying with the HOB flat. CNA 1 verified she placed Resident 23's HOB flat while the GT feeding was still infusing. CNA 1 stated she should have asked the nurse to put the GT feeding on hold before lying Resident 23 flat. On 3/12/24 at 1546 hours, an interview was conducted with LVN 2. LVN 2 stated the residents on the GT feeding should be placed with the HOB elevated at a 45 degree angle to prevent aspiration. LVN 2 further stated she did not expect the GT feeding to be infusing if the resident was lying with the HOB flat. On 3/13/24 at 0922 hours, an interview was conducted with the DON. The DON stated the staff were aware they should not lower the HOB when the GT feeding was infusing due to the risk of aspiration. On 3/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings. b. On 3/11/24 at 1020 hours, Resident 23 was observed lying in bed with the GT feeding infusing Jevity 1.2 at 60 ml/hr. Resident 23 was observed with the HOB flat. RNA 1 was in the room to assist CNA 1 to reposition Resident 23. RNA 1 was observed turning of the enteral tube feeding. On 3/11/24 at 1024 hours, an interview was conducted with RNA 1. RNA 1 verified she turned off the GT feeding for Resident 23. On 3/12/24 at 1441 hours, a follow-up interview was conducted with RNA 1. RNA 1 stated the HOB should be elevated more than 30 degrees when the GT feeding was infusing to prevent aspiration. When asked about operation of the GT feeding, RNA 1 stated she needed to get a licensed nurse to hold the GT feeding before lying the resident flat. RNA 1 further stated the LVNs were responsible for resuming and holding GT feedings. On 3/12/24 at 0922 hours, an interview was conducted with the DON. The DON stated the CNAs were expected to notify the charge nurse to hold GT feedings when providing care. The DON further stated the CNAs should not put the GT feedings on hold or to resume the feedings. On 3/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 3/11/24 at 1001 hours, an observation and concurrent interview of Resident 2 was conducted. An oxygen concentrator was observed next to Resident 2's bed. The oxygen concentrator was turned off. An oxygen tubing was connected to the concentrator and lying on top of the oxygen concentrator. The oxygen tubing was not labeled and bagged. Resident 2 stated she received oxygen when she needed it. Medical record review for Resident 2 was initiated on 3/11/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/20/23, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Physician Orders for March 2024 failed to show a physician's order for the oxygen administration. On 3/12/24 at 1444 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified there was no physician's order for the oxygen administration for Resident 2. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care for four of 14 final sampled residents (Residents 1, 2, 16, and 18). * The facility failed to follow the physician's order for administering the oxygen at 2 LPM instead of 3.5 LPM for Resident 1. * The facility failed to ensure the oxygen tubing was stored and labeled properly for Resident 2. In addition, the facility failed to obtain a physician's order for the oxygen therapy for Resident 2. * The facility failed to ensure the oxygen nebulizer mask and tubing were stored properly and labeled for Resident 16. * Resident 18's nasal cannula was improperly stored. These failures posed the risk for the residents' safety and respiratory related complications including infection. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to verify that there is a physician's order for this procedure; review the physician's orders or facility protocol for oxygen administration; change the oxygen cannula and tubing every seven days, or as needed; and keep the oxygen cannula and tubing used PRN in a plastic bag when not in use. 1. On 3/12/24 at 0825 hours, Resident 1 was observed receiving oxygen via nasal cannula at 3.5 L/min. The oxygen tubing was labeled and dated 3/11/24. Medical record review for Resident 1 was initiated on 3/11/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Physician's Orders dated March 2024 showed a physician's order dated 9/12/22, for the oxygen inhalation at 2 LPM via nasal cannula for SOB and to keep the oxygen saturation levels greater than 92%. On 3/12/24 at 0829 hours, an interview and concurrent record review was conducted with LVN 3. LVN 3 verified Resident 1 should have had his oxygen administration on at 2 LPM as ordered by the physician. 3. Medical record review for Resident 16 was initiated on 3/11/24. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 16's physician's order dated 11/30/23, showed an order to administer Iprat-albut 0.5-3 (2.5) mg/3 ml (a medication used to reduce inflammation in the airways), give one unit via nebulizer inhalation every four hours as needed for shortness of breath. On 3/11/24 at 0921 hours, Resident 16 was observed in bed. A nebulizer facemask and tubing was attached to the nebulizer machine. The facemask was stored inside a box labeled non-woven drain sponges. The facemask and tubing were not observed with a label. On 3/11/24 at 0929 hours, an observation and concurrent interview was conducted with the DON. The DON verified the above findings and stated the nebulizer facemask was just thrown on the side and should be labeled and stored in a respiratory bag. 4. Medical record review for Resident 18 was initiated on 3/11/24. Resident 18 was admitted to the facility on [DATE]. On 3/11/24 at 0907 hours, an observation and concurrent interview was conducted with Resident 18. An oxygen concentrator was observed adjacent to Resident 18's bed. Unlabeled oxygen tubing/nasal cannula was observed lying on top of the oxygen concentrator. Resident 18 stated she utilized the oxygen as needed for shortness of breath. Resident 18 stated she last utilized oxygen via nasal cannula a few weeks ago. On 3/11/24 at 0929 hours, an observation and concurrent interview was conducted with the DON. The DON verified the unlabeled oxygen tubing/nasal cannula was observed lying on top of an oxygen concentrator adjacent to Resident 18's bed. The DON stated the nasal cannula should be stored in a respiratory bag when not in use for infection control.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided for one of 14 final sampled residents (Resident 2). * The facility failed to monitor and accurately document Resident 2's fluid intake. * The facility failed to show evidence Resident 2's monthly weight was monitored and recorded. * The facility failed to update Resident 2's comprehensive plan of care to reflect the current dialysis access site. These failures had the potential to result in health complications for Resident 2. Findings: Review of the facility's P&P titled End-Stage Renal Disease, Care of a Resident revised 9/2010 showed the residents with end-stage renal disease (ESRD) will be care for according to currently recognized standards of care. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. Review of the facility's P&P titled Encouraging and Restricting Fluids revised 10/2010 showed the purpose of this procedure is to provide the resident with the amount of fluids necessary to maintain ioptimum health. This may include encouraging or restricting fluids. Follow specific instructions concerning fluid intake or restrictions. Be accurate when recording fluid intake. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessment of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Review of the facility's P&P titled Weighing and Measuring the Resident revised 3/2011 showed the purpose of this procedure are to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident, and to provide a baseline height in order to determine the ideal weight of the resident. Weight is usually measured upon admission and monthly during the resident's stay. The height and weight of the resident should be recorded in the resident's medical record. Medical record review for Resident 2 was initiated on 3/12/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/20/23, showed Resident 2 had the capacity to understand and make decisions. Further review of Resident 2's H&P examination dated 6/20/23, showed Resident 2 had a diagnosis of CKD-5 (Chronic Kidney Disease-Stage 5- a condition meaning kidney failure, also known as end-stage kidney disease) and on hemodialysis (the process of filtering wastes and water from the blood as the kidneys did when they were healthy. It helps control blood pressure and balance important minerals such as potassium, sodium, and calcium in the blood). a. Review of Resident 2's Physician's Orders dated 3/2024 showed a physician's order dated 8/30/23, for 1000 ml/24 hr fluid restriction as follows: Dietary: breakfast 210 ml, lunch 210 ml, and dinner 210 ml; Nursing: 7-3 shift 130 ml, 3-11 shift 120 ml, 11-7 shift 120 ml. On 03/11/24 at 0945 hours, an interview was conducted with Resident 2. Resident 2 stated she was on fluid restriction; however, she did not know how much. Review of Resident 2's MAR dated January 2024 showed the 1000 ml/24 hr fluid restriction order: Dietary: breakfast 210 ml, lunch 210 ml, and dinner 210 ml; Nursing: 7-3 shift 130 ml, 3-11 shift 120 ml, 11-7 shift 120 ml, with an order date of 8/30/23. The scheduled times were at 0600, 1400, and 2200 hours. Further review of the January 2024 MAR showed on 1/2, 1/4, 1/6, 1/8, 1/10, 1/12, 1/14, 1/16, 1/18, 1/20, 1/22, 1/24, 1/26, 1/28, and 1/30/24, did not have the amount of fluid intake recorded for the scheduled times for Resident 2. The dates and times were marked with asterisks. In addition, the MAR for the whole month of January 2024 showed documentation of total fluid intake consumed from all three shifts, even when there were no fluid amount recorded on the specified dates. Review of Resident 2's MAR dated February 2024 showed the 1000 ml/24 hr fluid restriction order: Dietary: breakfast 210 ml, lunch 210 ml, and dinner 210 ml; Nursing: 7-3 shift 130 ml, 3-11 shift 120 ml, 11-7 shift 120 ml, with an order date of 8/30/23. The scheduled times were at 0600, 1400, and 2200 hours. Further review of the February MAR showed one 2/1, 2/3, 2/5, 2/7, 2/9, 2/11, 2/13, 2/15, 2/17, 2/19, 2/21, 2/23, 2/25, 2/27, and 2/29/24, did not have the amount of fluid intake recorded for the scheduled times for Resident 2. The dates and times were marked with asterisks. In addition, the MAR for the whole month of February 2024 showed documentation of total fluid intake consumed from all three shifts, even when there were no fluid amount recorded on the specified dates. Review of Resident 2's MAR from 3/1 to 3/11/24, showed the 1000 ml/24 hr fluid restriction order: Dietary: breakfast 210 ml, lunch 210 ml, and dinner 210 ml; Nursing: 7-3 shift 130 ml, 3-11 shift 120 ml, 11-7 shift 120 ml, with an order date of 8/30/23. The scheduled times were at 0600, 1400, and 2200 hours. Further review of the March MAR showed on 3/2, 3/4, 3/6, 3/8, and 3/10/24, did not have the amount of fluid intake recorded for the scheduled times for Resident 2. The dates and times were marked with asterisks. In addition, the MAR showed documentation of total fluid intake consumed from all three shifts, even when there were no fluid amount recorded on the specified dates. On 3/12/24 at 1347 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified Resident 2's fluid restriction of 1000 ml/24 hrs as ordered by the physician. LVN 3 also verified the MAR for January, February, and March 2024 showed blank boxes with asterisks and Resident 2's fluid intake was not documented daily on the MAR. When asked what the asterisk meant, LVN 3 stated it looked like the facility was checking the fluid restriction every other day. LVN 3 also stated the total fluid intake was recorded at midnight for the day prior. On 3/14/24 at 1146 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the charge nurse knew how much fluids Resident 2 consumed and they factored in the fluids given to Resident 2 during medication administration. The DON stated fluid restriction should be documented in the MAR every shift and the night shift documented the total fluid intake. The DON verified the fluid was not documented accurately and there was a total fluid intake for the 3 shifts in spite of the missing fluid documented in the MAR. b. Review of Resident 2's form titled MONTHLY RECORD OF V/S AND WTS showed a weight was recorded for 7/2023, as 133 (not specified whether pounds or kilograms). The form did not show documentation of Resident 2's weight for August through December 2023 and January through March 2023. Review of the Resident 2's Weight Change History dated 6/19/23 through 3/12/24, showed documentation of post-dialysis weights. Review of Resident 2's Plan of Care showed a care plan problem dated 6/18/23, for Nutrition: at risk d/t ESRD; on Dialysis. The interventions included to take admission weight and weekly x 4 weeks, then monthly; re-eval as needed. On 3/14/24 at 0821 hours, an interview and concurrent medical record review was conducted with the Dietary Supervisor. The Dietary supervisor stated there was a binder from dialysis. All residents were weighed monthly unless there was a different order, and weights were documented in a binder and in the computer. The Dietary supervisor verified the monthly vital sign and weight records did not have weights recorded form August 2023 to February 2024. On 3/14/24 at 1128 hours, an interview was conducted with the DON. When asked regarding the facility's process in weighing the residents, the DON stated the residents were weighed monthly unless the residents had a different order. The DON stated for the dialysis residents, the facility used the post-dialysis weight that was sent back with the resident. When asked if the facility should have recorded the monthly weights for the dialysis, the DON stated yes. On 3/14/24 at 1204 hours, the DON provided the facility's monthly weight log for 2023 and 2024. Resident 2 did not have documentation of monthly weights on the log for 2023 and 2024. The DON verified the findings. c. Review of Resident 2's Physican Orders dated March 2024 showed a physician's order dated 6/26/23, to monitor LUA AV Shunt for Bruit/Thrill EQS. On 3/11/24 at 0955 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 stated she had been on hemodialysis for 12 years and scheduled to receive dialysis three times per week (Monday, Wednesday, and Friday). Resident 2 showed and was observed to have her dialysis access site on her a left upper arm. Review of Resident 2's Plan of Care showed a care plan problem dated 6/18/23, for renal disease requiring dialysis. The care plan interventions included the following: - Monitor the right Upper Chest Permacath for s/sx (signs and symptoms) of infection and for dressing intact - Monitor the Dialysis Access site Right Femoral Permacath for s/sx of infection - Monitor the LUA (left upper arm) AV (arteriovenous shunt) Shunt for Bruit/Thrill EQS On 3/13/24 at 1034 hours, an interview was conducted with Resident 2. Resident 2 stated the only access used for dialysis was in the left upper arm. Resident 2 further stated she used to have a dialysis catheter in her chest, but it was removed a year ago. On 3/14/24 at 1127 hours, an interview was conducted with the DON. The DON verified Resident 2 had a left upper arm AVF currently in use for dialysis treatment. The DON stated Resident 2 did have a femoral site in the right groin, which was temporary, until the permanent shunt was placed. The DON also verified the care plan still showed the femoral permacath and right upper chest permcath as still active and stated it should have been removed. The DON further stated the staff should review the care plan for accuracy and update it as needed.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Proper Use of Side Rails last revised on 12/16 showed an assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. In addition, consent for side rail use must be obtained from the resident or legal representative after presenting potential benefits and risks. On 3/13/24 at 0817 hours, Resident 1 was observed resting in bed with the bilateral upper side rails elevated. Medical record review for Resident 1 was initiated on 3/13/24. Resident 1 was admitted to the facility on [DATE]. Further review the resident's medical record failed to show documented evidence a physician's order for the use of bilateral side rails for Resident 1. In addition, Resident 1's medical record failed to show the informed consent was obtained for the use of the bilateral side rails. On 3/13/24 at 0824 hours, an interview conducted with RNA 1. RNA 1 stated the resident should not have the side rails up. On 3/13/24 at 0940 hours, a concurrent record review and interview with LVN 3 was conducted. LVN 3 verified Resident 1 had no consent and care plan for side rails use. LVN 3 further stated the consent, care plan, and entrapment risks assessment were required prior to the use of side rails. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 14 final sampled residents (Residents 1 and 12) remained free from accident hazards related to the use of elevated side rails. * Resident 12 was observed with elevated side rails in place. The facility failed to review the risks and benefits of the side rails with Resident 12 and/or responsible party and failed to obtain the informed consent for the use of the side rails. * Resident 1 was observed in bed with the elevated side rails. However, there was no physician's order, care plan, and informed consent for the use of side rails. These failures had the potential to place the residents at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Proper Use of Side Rails revised 12/2016 showed the consent for using restrictive devices will be obtained from the resident and legal representative per facility protocol. The consent for the side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks. 1. On 3/11/24 at 0906 hours, and 3/12/24 at 1205 hours, Resident 12 was observed lying in bed with the bilateral upper side rails elevated. Medical record review for Resident 12 was initiated on 3/11/24. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's Physician Orders dated 3/2024 showed a physician's order dated 3/11/24, may have bilateral upper side rails up while in bed for increased bed mobility and repositioning. Further review of Resident 12's medical record failed to show the informed consent was obtained for the use of bilateral side rails. On 3/13/24 at 1347 hours, the DON acknowledged the above findings and verified there was no informed consent completed for the use of bilateral side rails. On 3/13/24 at 1611 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 12 used the side rails for turning and needed moderate assistance to turn.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P, the facility failed to ensure the pharmaceutical services were provided to meet the needs for one of 14 final sampled residents (Resident 2). * The facility failed to administer Sevelamer Carbonate (medication to treat too much phospate in the blood in residents with chronic kidney disease who are on dialysis) with meals as ordered by the physician. * The facility failed to monitor and document the blood pressure prior to administration of Midodrine (medication to increase blood pressure) as ordered by the physician. These failures had the potential to negatively affect the resident's health. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019, showed medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 2 was initiated on 3/11/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 6/20/23, showed Resident 2 had the capacity to understand and make decisions. 1. Review of Resident 2's Physician Orders dated March 2024 showed a physician's order dated 6/18/23, for Sevelamer Carbonate 800 mg TAB PO TID with meals for hyperphosphatemia (too much phosphate in the blood). On 3/14/24 at 0805 hours, LVN 4 was observed going inside Resident 2's room to administer medications. On 3/14/24 at 0810 hours, an interview was conducted with LVN 4. LVN 4 verified one of the medications she administered to Resident 2 was the Sevelamer Carbonate 800 mg. LVN 4 also verified the direction and physician's order was to administer Sevelamer with meals. LVN 4 verified she did not administer the Sevelamer with meals to Resident 2 because she was busy with another resident. LVN 4 acknowledged she should have given the Sevelamer with meals. 2. Review of Resident 2's Physician Orders dated March 2024, showed a physician's order dated 9/17/23, to give Midodrine HCL 5 mg one tablet PO Q eight hours for hypotension. HOLD if SBP>130 mmHg. Review of Resident 2's MAR for February and from 3/1 -3/12/24, showed the Midodrine was administered at 0600, 1400, and 2200 hours. The last administration of the medication at the time of record review was 3/123/24, at 0600 hours. The MARs failed to show documented evidence Resident 2's blood pressure was monitored and recorded prior to the administration of Midodrine. On 3/14/24 at 1416 hours an interview and concurrent medical record review was conducted wit the DON. The DON verified the blood pressure was not documented in the MAR as ordered prior to administering Midodrine to Resident 2.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the pharmacy consultant's recommendations were acted upon for one of 14 final sampled (Resident 10). This failure had the potential for the resident not receiving the necessary care and services. Findings: Medical record review for Resident 10 was initiated on 3/11/24. Resident 10 was readmitted to the facility on [DATE]. Review of Resident 10's Physician Orders for 3/2024, showed a physician's order dated 1/19/24, to administer metoprolol tartrate 25 mg tablet PO (by mouth/orally) two times a day for hypertension (high blood pressure); and to hold if the heart rate less than 60 beats per minute or systolic blood pressure greater than 110 mmHg. Review of the facility document titled Medication Regimen Review Report dated 1/2024 showed a medication review completed by the Pharmacist Consultant for Resident 10. The recommendation showed for metoprolol tartrate (blood pressure medication) to be given with food and to consider adding vitamin C 500 mg once daily with ferrous sulfate to help with iron absorption. On 3/12/24 at 1558 hours, a concurrent interview and record review was conducted with the DON. The DON verified the Pharmacist Consultant's recommendations regarding the metoprolol administration and vitamin C were not acted upon. The DON stated the charge nurse was responsible to complete the recommendations.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 12) was free from unnecessary psychotropic drugs (any drug that affects brain activity). * The facility failed to ensure the informed consent was obtained from Resident 12's responsible party for the use of Remeron (an antidepressant drug which can be taken as an appetite stimulant). This failure posed the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Psychotropic Medication Use dated 7/2022 showed the residents (and/or representatives) have the right to decline treatment with psychotropic medications. The staff and physician will review with the resident/representative the risks related to not taking the medication as well as appropriate alternative. Medical record review for Resident 12 was initiated on 3/11/24. Resident 12 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 12's H&P examination dated 11/5/23 and 3/10/24, showed Resident 12 did not have the capacity to understand and make decisions and Resident 12's surrogate decisionmaker was Resident 12's family member. Review of Resident 12's Physician Orders dated 3/2024 showed a physician's order dated 3/11/24, for Remeron 15 mg tablet, take one tablet by mouth at bedtime for depression manifested by poor appetite. Further review of Resident 12's medical record failed to show Resident 12 and the resident's responsible party were informed of the risks, benefits, and alternatives of taking the psychotropic medication Remeron and consented to the use of the medication. On 3/13/24 at 0940 hours, a concurrent interview and medical record review was conducted with the DON. The DON was asked regarding the facility's process for psychotropic medication use. The DON stated if the medication was initiated in the facility, they needed to have attempted alternatives, documentation of behaviors, and informed consent. The DON stated Resident 12's Remeron was started in the facility on her previous admission and the facility should have consent. On 3/13/24 at 1347 hours, the DON verified there was no informed consent completed for the use of Remeron medication.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the facility's P&P titled Storage of Medication revised 4/2019 showed the discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. On [DATE], at 1115 hours, a wound care observation was made with the QA/IP for Resident 1. The QA/IP stated the LVNs usually provided wound care treatment; however, she also assisted as needed. The QA/IP stated prior to wound care, she would take the following steps: perform hand hygiene, verify order, gather supplies, provide privacy, and explain to the resident about the procedure. In addition, she would assess for wound site, pain tolerance, and inform the physician if abnormal findings were noted. The QA/IP reviewed the physician's order for the wound care initiated on [DATE], for the right shoulder cancer wound showed to cleanse with NS, pat dry, apply TAO, and leave open to air QD (daily) for 14 days and re-evaluate on [DATE]. When the treatment cart was inspected and opened, the following expired items were found: 4 Sureprep pads and one suture kit. The QA/IP verified the findings and stated the wound care cart was checked monthly and should not have any expired items. 5. Review of the US FDA's consumer update titled Safely Using Hand Sanitizer dated [DATE], showed hand sanitizers are regulated as over-the-counter (nonprescription) drugs by the US FDA. On [DATE] at 0912 hours, an isolation cart was observed outside of Resident 16's room. There was a hand sanitizer bottle and germicidal wipes on top of the cart. The hand sanitizer bottle's expiration date was [DATE]. On [DATE] at 0825 hours, a concurrent observation and interview was conducted with the Housekeeping staff. The Housekeeping staff verified there were hand sanitizer bottles in all the rooms, dining room, and in the hallways. The Housekeeping staff stated the hand sanitizer bottles in the hallways and rooms were changed when they were done. Three different bottles of hand sanitizer were observed with expiration dates of 7/2022, 5/2023, and 4/2023. The Housekeeping staff verified the hand sanitizer bottles were expired. On [DATE] at 0834 to 0844 hours, a concurrent observation and interview was conducted with the DON. The DON stated she ordered the supplies for the facility and would replace the hand sanitizer bottles when the staff let them know. The DON stated the hand sanitizer bottles were in every room or by the room and medication cart. The DON verified the above findings and stated the IP and charge nurses were responsible to make sure the hand sanitizers were not expired. The DON and QA/IP nurse were observed to collect all the 25 hand sanitizer bottles out of the medication cart, rooms and hallways. The DON verified the facility had three more cases of 24 expired hand sanitizer bottles in the facility (a total of 97 expired bottles). Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure proper storage of medications in the Medication Cart. The facility failed to ensure treatment supplies were not expired in the Treatment Cart. The Facility failed to ensure the expired hand sanitizer bottles were discarded. * Discontinued prednisone (steroid) tablets were observed in the Medication Cart. * The facility failed to ensure a container of germicidal alcohol wipes was stored separately from the residents' medications. * An unlabeled and unpackaged vial of ipratropium and albuterol (combination medication that relaxes muscles in the airways and increase air flow to the lungs) inhalation solution was observed lying in the Medication Cart. * Within the Medication Cart, two 30-ounce bottles of wild cherry Pro-Stat (protein supplement) and one 16-ounce bottle of Milk of Magnesia (laxative & antacid) were observed with an unknown substance accumulated on the outside of the bottles. * A used surgical mask was observed inside the top drawer of the Medication Cart. The surgical mask was observed adjacent to the medications/supplements. * Ipratropium and albuterol inhalation solution unit dose vials were packaged in clear plastic versus foil and were not used within 1 week of removal from foil packaging. * The expired supplies were observed in the Treatment Cart. * The hand sanitizer bottles expired between 7/2022 through 5/2023 were utilized in the resident rooms, hallways, dining room, and medication cart. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Storage of Medications revised 4/2019 showed antiseptics, disinfectants, and germicides used in any aspect of resident care have legible, distinctive labels that identify the contents and the directions for use, and are stored separately from regular medications. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Drugs and biologicals are stored in the packaging, containers, or other dispensing system in which they are received. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of the facility's P&P titled Discontinued Medications revised 4/2017 showed staff shall destroy discontinued medications. No medication shall be returned to the dispensing pharmacy once received by the facility. 1. On [DATE] at 0825 hours, a medication administration observation was conducted with LVN 4. Medical record review for Resident 12 was initiated on [DATE]. Review of Resident 12's physician's telephone order dated [DATE] at 1822 hours, showed an order to discontinue prednisone (corticosteroid medication) 10 mg orally daily, and change prednisone to 5 mg orally daily. However, Resident 12's prednisone 10 mg medication bubble pack was observed inside the Medication Cart. The bubble pack contained several prednisone 10 mg tablets, with instructions to administer daily in the morning. LVN 4 stated on [DATE], Resident 12's physician discontinued prednisone 10 mg orally daily. LVN 4 stated Resident 12's physician changed Resident 12's prednisone dose to 5 mg orally daily to begin on [DATE]. LVN 4 stated she would remove Resident 12's discontinued prednisone 10 mg tablets from the Medication Cart and place the discontinued medications in the medication room to be discarded. LVN 4 stated removal of discontinued medications from the resident medication cart was to ensure discontinue medications were not administered in error. 2. On [DATE] at 1400 hours, an inspection of the facility's Medication Cart was conducted with LVN 4. The following was observed: a. A container of germicidal alcohol wipes was observed stored in the bottom drawer of the medication cart adjacent to boxes (60 units) of resident inhalation medication (Albuterol Sulfate inhalation solution 2.5 mg/3 ml). LVN 4 verified the finding. b. An unlabeled and unpackaged vial of ipratropium and albuterol inhalation solution was observed in the Medication Cart, lying on the bottom of the bottom drawer. LVN 4 verified the findings and stated she would discard the medication vial. c. Within the Medication Cart, two 30-ounce bottles of wild cherry Pro-Stat and one 16-ounce bottle of Milk of Magnesia were observed with an unknown substance accumulated on the outside of the bottles. LVN 4 verified the findings. d. A used surgical mask was observed inside the top drawer of the Medication Cart. The surgical mask was observed adjacent to the medications/supplements, including, fish oil soft gels, throat lozenges, multivitamin tablets, loperamide (anti-diarrheal medication) tablets, and phenylephrine hcl (nasal decongestant medication) tablets. LVN 4 verified the findings and stated she utilized the mask during the medication pass and should have thrown the mask in the trash for infection control, and not stored the mask in the Medication Cart adjacent to the resident's medications. 3. According to [NAME] drug, ipratropium and albuterol inhalation solution unit dose vials should be stored in a foil pouch until use and used within one week of the removal from the foil pouch. On [DATE] at 0945 hours, an inspection of the facility's Medication Cart was conducted with the DON. Medical record review for Resident 19 was initiated on [DATE]. Review of Resident 19's physician's orders showed an order dated [DATE], for ipratropium and albuterol 0.5-3(2.5) mg /3 ml inhalation one vial via handheld nebulizer every four hours as needed for shortness of breath. Inside of the Medication Cart, a clear plastic bag labeled with Resident 19's name contained eight vials of ipratropium and albuterol 0.5-3(2.5) mg/3 ml inhalation solution. The label showed a fill date of [DATE]. The DON verified the ipratropium and albuterol 0.5-3(2.5) mg/3 ml inhalation solution was not packaged in foil.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal vaccine was administered to one of 14 final sampled residents (Resident 17). This failure put Resident 17 at risk for pneumonia. Findings: Review of the facility's P&P titled Pneumococcal Vaccine revised 10/2019 showed all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provisions of such education shall be documented in the resident's medical record. Pneumococcal vaccines will be administered to residents (unless medically contraindicated, already given, or refused) per the facility's physician-approved pneumococcal vaccination protocol. Medical record review for Resident 17 was initiated on 3/14/24. Resident 17 was admitted to the facility on [DATE]. Review of the Pneumococcal Vaccine Informed Consent dated 5/9/23, showed a consent was obtained for Resident 17 to receive the pneumococcal vaccination. Review of the facility's Immunization History Report with a date range of 3/14/20 to 3/14/24, failed to show documented evidence Resident 17 received the pneumococcal vaccination. On 03/14/24 at 1055 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified a consent for Resident 17 was obtained on 5/9/23, to receive the pneumococcal vaccination and no documented evidence the facility's Immunization History Report showing Resident 17 received the pneumococcal vaccination. On 03/14/24 at 1508 hours, a follow-up interview was conducted with the IP. The IP stated Resident 17's consent dated 5/9/23, to receive the pneumococcal vaccination was not followed through and there was no physician's order for Resident 17 to have the pneumococcal vaccination.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential kitchen equipment was maintained in safe operation condition when the ice machine manufacturer cleaning and sanitizing instructions were not followed. This failure had the potential to result in the equipment to not function in the way it was intended which could affect the health status of the residents. Findings: Review of the facility P&P titled Sanitization revised 12/08 showed ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the ice machine instruction manual titled Automatic Ice Maker undated, under the section for Cleaning and Maintenance, showed the ice machine must be cleaned by use of a water jet; for interior cleaning, the ice storage bin should be sanitized occasionally by wiping down the interior with a sanitizing solution made of 28 grams (g) of household bleach or chlorine and 7.5 liters (L) of hot water. Further review of the manual, under the section Ice Making Part Cleaning, showed the water tank and the ice-full detecting plate are very important to keep the ice cube hygienic. The instructions showed to put the mixture of neutral cleaner and water into a clean water jet, then spray all the inner surface of the tank and the ice detecting plate. On 3/12 /24 at 0945 hours, an observation of the facility's ice machine located in the activity room and concurrent interview with the DSS was conducted. The DSS was asked to describe how she cleaned the ice machine. The DSS stated the ice machine was deep cleaned every six months. The DSS stated she removed all the ice and cleaned the inside by wiping down the inside with the recommended Nu-Calgon [NAME] Safe Ice-machine Cleaner. Then, she rinsed the inside with a water and Sani-10% (Disinfectant Sanitizer) solution to sanitize, followed by a rinse with the regular water. On 3/ 13/24 at 1043 hours, a follow-up interview and concurrent review of the ice machine manufacturer instruction manual was conducted with the DSS. The DSS was asked to clarify how she cleaned the inner parts of the ice machine. The DSS stated she used a disposable towel with Nu-Calgon [NAME] Safe Ice-Machine Cleaner solution to wipe the crevices and the ice tray. The DSS stated she then used Sani-10% solution to rinse the inside of the ice machine, followed by a rinse with water. Concurrent review of the ice machine instruction manual was conducted with the DSS. The DSS verified she did not use a water jet to clean the internal parts of the ice machine and verified the manual instructed to use household bleach or chlorine to sanitize the ice machine. The DSS stated Sani-10% did not contain bleach or chlorine. On 3/14/24 and 1426 hours, the DSS and Administrator were informed and acknowledged the above findings.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when: * Time/Temperature Control for Safety (TCS) foods (food that require time and temperature controls to limit the growth of illness causing bacteria) were not accurately monitored to ensure proper cool down process was followed. * The facility failed to ensure the handwashing sink was used for handwashing only. * The facility failed to ensure proper labeling and dating of food in the refrigerator used for resident foods. * The facility failed to ensure the kitchen utensils were clean and stored in sanitary condition. * The facility failed to ensure the cutting boards were kept in sanitary condition. * The facility failed to ensure the kitchen utensils and equipment were kept in good repair. * The facility failed to ensure the kitchen equipment were air dried. * The facility failed to ensure the dented cans were removed. These failures had the potential to cause foodborne illness in a highly susceptible resident population of 23 facility residents who consumed food prepared in the kitchen. Findings: Review of the facility's matrix showed 23 of 26 residents consumed food prepared in the kitchen. 1. According to the USDA Food Code 2022, Section 3-501.14 Cooling, (A) Cooked time/temperature control for safety food shall be cooled: (1) within two hours from 135 degrees Fahrenheit (F) to 70 degrees F; and (2) within a total of six hours from 135 degrees F to 41 degrees F or less, (B) Time/temperature control for safety food shall be cooled within 4 hours to 41 degrees F or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. Review of the facility's P&P titled Cooling and Reheating of Potentially Hazardous or Time/Temperature Control for Safety Food dated 2023 showed cooked potentially hazardous foods (PHF) or time/temperature control for safety (TCS) foods shall be cooled and reheated in a method to ensure food safety. The Procedure section, showed when cooked PHF or TCS food are not served right away, it must be cooled as quickly as possible using the Two-Stage Method: (a) cool cooked food from 140 degrees F to 70 degrees F within two hours, and (b) then cool from 70 degrees F to 41 degrees F or less in an additional four hours for a total cooling time of six hours. The facility's P&P also showed to use the Cool Down Log to document proper procedure when cooling down food. Review of the facility's Menu for 3/8/24, showed the following entrees were served for dinner: turkey salad on bed of lettuce, corn chowder, tomato slice, wheat roll, and baked apricot crunch. Review of the Daily Food Temperatures Log showed on 3/8/24, for dinner, the main entrée was documented as 36 degrees F. Review of the facility's Cool Down Log showed once food drops to 140 degrees, to begin the cooling procedure; the temperature at 2 hours or less: if 70 degrees F or less, you have four more hours to get temperature to 41 degrees F or less. If more than 70 degrees after two hours, to take corrective actions per policy. Further review of the Cool Down Log showed an entry dated 3/8/24, for roast turkey. The log showed on 3/8/12 at 1200 hours, the temperature of the roast turkey was 190 degrees F. The entry also showed the roast turkey was cooled to 70 degrees F; however, a time was not indicated. Furthermore, the log failed to show when the roast turkey reached 41 degrees F or below. On 3/12/24 at 1400 hours, an interview and concurrent review of the Cool Down Log was conducted with the DSS. The DSS stated the cooling process for meats should start at 140 degrees F, and after two hours, the temperature should reach 70 degrees F, followed by four hours to reach at 41 degrees F. Concurrent review of the Cool Down Log was conducted with the DSS. The DSS stated she did not know what time the cool down process was started for the roast turkey on 3/8/24, and she did not know what time the temperature reached at 70 degrees F. The DSS further stated it was important to know the times because certain foods at certain temperatures and durations of time may cause bacteria growth. On 3/14/24 and 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. 2. According to the USDA Food Code 2022 5-205.11 Using a Handwashing Sink, a handwashing sink may not be used for purposes other than handwashing. On 3/11/24 at 0810 hours, an initial tour of the kitchen was conducted with [NAME] 1. The handwashing sink was observed with red and green sanitation and cleaning buckets near the faucet. A sign above the handwashing sink showed for handwashing only. [NAME] 1 verified the above finding. On 3/11/24 at 1620 hours, and interview was conducted with the DSS. The DSS stated the handwashing station should be used for handwashing only. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledge the findings. 3. Review of the facility P&P titled Labeling and Dating of Foods dated 2023 showed all food items in the storeroom, refrigerator, and freezer need to be labeled and dated. On 3/11/24 at 1224 hours, an observation of the refrigerator used to store the resident's food brought in by the visitors and concurrent interview was conducted with the DSS. An unopened ready care shake was noted in the refrigerator, without a resident's name or a use-by date. The label on the shake showed to use within 14 days of thawing. The DSS stated she did not know when the shake was removed from the freezer or when it was placed in the refrigerator. A frozen plastic water bottle was observed in the freezer without a resident name and use-by date. The DSS stated she did not know who the water bottle belonged to. The DSS was observed removing the two items and discarding in the trash. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. 4. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use articles, cleaned equipment and utensils, laundered linens, and single-service and single-use articles shall be stored in a clean, dry location. Review of the facility's P&P titled Sanitation dated 2023 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair, and shall be free from breaks, corrosions, open seams, cracks, and chipped areas. On 3/11/24 at 0810 hours, during the initial tour of the kitchen, two scoops were observed with dry white remnants in the inner side of the scoop, and stored in a drawer of clean kitchen utensils. The drawer was observed with dry, yellow-brown food particles at the bottom of the drawer. [NAME] 1 verified the above findings. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. 5. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces. On 3/11/24 at 0810 hours, during the initial tour of the kitchen, two cutting boards were observed heavily marred with knife marks. [NAME] 1 verified the above findings. On 3/11/24 at 1620 hours, an interview was conducted with the DSS. The DSS stated cutting boards were replaced once a year or depending on the condition of the cutting boards. The DSS was shown pictures of the cutting boards obtained during the initial tour and stated the cutting boards should be changed. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledged the above findings. The DSS stated the cutting boards have been replaced. 6. According to the 2022 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints. Review of the facility's P&P titled Sanitation dated 2023 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas. On 3/11/24 at 0810 hours, during an initial tour of the kitchen, one white spatula was observed chipped and discolored, a portion server was observed with a partially melted green handle, and a can opener was observed with chipped stainless steel coating, exposing the blade. [NAME] 1 verified the above findings. [NAME] 1 stated the can opener blade should be changed when the coating on the blade have noticeable chips. On 3/11/24 at 1620 hours, an interview was conduced with the DSS. The DSS was shown the pictures of the spatula, melted green handle, and chipped coating from the can opener blade. The DSS stated the items should be changed. On 3/14/24 at 1426 hours, the DSS and Administrator were notified and acknowledged the above findings. The DSS stated the can opener blade had been replaced, and the spatula and melted server scoop had been removed. 7. According to the USDA Food Code 2022 Section 4-901.11, Equipment and Utensils, Air-Drying Required, after cleaning and sanitizing, equipment and utensils shall be air dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. Review of the facility's P&P titled Sanitization revised 2008 showed food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. On 3/11/24 at 0810 hours, during a tour of the kitchen, an interview and concurrent observation was conducted with [NAME] 1. Multiple clear containers and one container lid were observed stored inside a cabinet, stacked upside down. The clear containers were observed still wet with visible water inside. [NAME] 1 verified the above findings and stated the containers should be air dried. [NAME] 1 was then observed laying the containers on a silver cart to air dry. On 3/11/24 at 1620 hours, an interview was conducted with the DSS. The DSS stated containers should be air dried completely before putting away. On 3/14/24 at 1426 hours, the DSS and Administrator were notified and acknowledged the above findings. 8. Review of the facility's P&P titled Food Storage-Dented Cans dated 2023 showed all dented cans and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. On 3/11/24 at 0810 hours, during an initial tour of the kitchen, an interview and concurrent observation was conducted with [NAME] 1. In the dry storage, two dented cans were observed on the shelf. [NAME] 1 verified the above finding and stated the dented cans should be moved to the area specified for dented cans. On 3/11/24 at 1620 hours, an interview was conducted with the DSS. The DSS stated she was responsible for checking the dented cans and removal of the cans from the shelf. The DSS stated she was informed by [NAME] 1 regarding the dented cans. On 3/14/24 at 1426 hours, the DSS and Administrator were informed and acknowledge the above findings. The DSS stated the dented cans had been removed from the shelf.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the appropriate infection control practices designed to provide a safe and sanitary environment and help prevent the development and transmission of infections were implemented. * The facility failed to show documentation of Legionella testing protocols. * The facility failed to ensure the personal items and food were not stored in the laundry room with clean linens for the residents. In addition, the facility failed to ensure the laundry soap, fabric softener, and Clorox were stored properly and in clean condition in the laundry room. * The facility failed to ensure CNA 1 performed hand hygiene after assisting Resident 19 with lunch and doffing her gloves. * The facility failed to ensure the urinals, basins, and tubs stored in a shared bathroom shelf were labeled. These failures had the potential to result in the transmission of infection to the vulnerable population of residents in the facility. Findings: 1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated 6/2/17, the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation that, at a minimum, ensure each facility: - Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained. Review of the facility's P&P titled Policy and Procedure pertaining to Legionella Bacteria dated 12/1/23, showed Legionella bacteria are common and can be found naturally in environmental water sources such as [NAME], lakes and reservoirs, usually in low numbers. Legionella bacteria may also enter purpose built water systems and can be found in cooling tower systems, hot and cold water systems and other plant which use or store water. On 3/14/24 at 1119 hours, an interview was conducted with the Administrator regarding the process for testing for Legionella bacteria in the water. The Administrator stated the facility had a fish tank in the lobby with one fish. The Administrator stated the fish tank was cleaned every two weeks and 15 to 25% of water was changed, and anything more than 25%, the fish would die. When asked if the facility conducted testing for Legionella, the Administrator stated, not in the fish tank and the facility did not have any free standing water. The Administrator further stated the facility followed the CDC guidelines. The facility failed to show documentation of its testing protocols for Legionella and other opportunistic pathogens in building water system, other than the fish tank located in the lobby. On 3/14/24 at 1329 hours, the Administrator verified the facility did not have documentation of its testing protocols for Legionella and other opportunistic pathogens in the building water systems other than the fish tank. On 3/14/24 at 1630 hours, a telephone interview was conducted the Maintenance Supervisor. The Maintenance Supervisor verified there was no testing done in the facility for Legionella. 2. Review of the the facility's P&P titled Policies and Procedures - Infection Control revised 10/2018 showed the facility's infection control practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. On 3/14/24 at 1425 hours, an observation of the laundry room and concurrent interview with Laundry 1 staff was conducted. An observation of the table designated for folding clothes, linens, sheets were observed with three one-gallon water bottles, one portable radio, cookies, one can of Coke, and one tostada stored on the second shelf of the table with the clean linens for the residents' use. Laundry 1 verified the personal items and food and stated she did not have a locker to store her personal items. In addition, two buckets of liquid Clorox, two buckets of liquid fabric softeners, and two buckets of liquid soap were found stacked on top of each other directly on the floor behind the dryer. One additional bucket of liquid fabric softener was found on a pedestal behind the dryer with dust and a black residue. Laundry 1 verified all the findings. 4. Review of the facility's P&P titled Infection Control last revised 10/2018 showed further support that infection control practice is intended to facilitate maintaining a safe, sanitary and comfortable environment and to help present and manage transmission of diseases and infections. On 3/11/24 at 1026 hours, an observation and concurrent interview were conducted with Resident 130. Resident 130 stated he had been at the facility for two months. Resident 130 had a roommate who shared the bathroom with the resident; however, the urinals, basins, and tubs were in the shared bathroom shelf not labeled. Resident 130 stated he preferred to have his belongings and supplies labeled. On 3/11/24 at 1115 hours, an interview was conducted with LVN 4. LVN 4 confirmed the resident should have all his belongings and supplies labeled, including urinal, basin and tubs. She further stated this approach assisted with maintaining sanitary and preventing the spread of diseases and illnesses. 3. Review of the facility's P&P titled Handwashing/ Hand Hygiene, undated, showed the facility considers hand hygiene the primary means to prevent the spread of infections. Employees must wash their hands for at least 15 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: - before and after direct resident contact - before and after assisting a resident with meals, - after removing gloves or aprons. Further review of the facility's P&P showed in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all of the following situations: - before and after direct contact with residents - after removing gloves. The P&P also showed hand hygiene is always the final step after removing and disposing of personal protective equipment. On 3/11/24 at 0849 hours, during the initial tour of the facility, an Enhanced Standard Precautions (ESP) sign was observed posted outside of Resident 19's room alerting anyone entering the room to don gloves and gown for the following high contact resident care activities: morning and evening care, toileting and changing incontinent briefs, caring for devices and medical treatments, wound care, mobility assistance and preparing to leave the room, or cleaning and disinfecting the environment. The sign showed for the residents who are on ESP, when performing activities from the six groups of care activities, to use hand hygiene, gloves, and gowns. On 3/11/24 at 1205 hours, CNA 1 was observed in Resident 19's room wearing gloves and no gown. CNA 1 was observed feeding Resident 19. CNA 1 was observed removing and discarding her gloves and leaving the room without performing hand hygiene. On 3/11/24 at 1207 hours, an interview was conducted with CNA 1. CNA 1 verified she did not perform hand hygiene after removal of her gloves and leaving Resident 19's room. CNA 1 stated hand hygiene should be performed before entering and exiting the residents' room and after removal of the gowns and gloves. On 3/13/24 at 0925 hours, an interview was conducted with the DON. The DON stated for the residents who were placed on ESP, the staff should don gloves and gown when providing certain care activities to prevent the spread of resistant organisms that could be potentially transferred to other residents. The DON stated Resident 19 was on ESP due to his urinary indwelling catheter and multiple wounds. The DON also stated the staff were expected to perform hand hygiene in between the residents and after removal of the gloves. On 3/14/24 at 1637 hours, the DON and Administrator were informed and acknowledged the above findings.

CONCERN (E)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility document review, and facility P&P review the facility failed to implement their Antibiotic Stewardship Program when the facility failed to conduct an accurate assessment for the McGeer's criteria for one of 14 final sampled residents (Resident 3) and one nonsampled resident (Resident 6). This failure had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics. Findings: According to the Centers for Disease Control and Infection, an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection with antibiotic-resistant organisms. The World Health Organization cites antibiotic resistance as one of the biggest threats to human health. Review of the facility's P&P titled Antibiotic Stewardship- Review and Surveillance of Antibiotic Use and Outcomes revised 12/2016 showed antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. As part of the facility Antibiotic Stewardship Program, all clinical infections treated with antibiotics will undergo review by the Infection Preventionist or designee. The IP, or designee, will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. Review of the closed medical records for Residents 3 and 6 was initiated on 3/11/24. - Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's facesheet showed Resident 3 was discharged from the facility on 3/11/24. -Resident 6 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 6's facesheet showed Resident 6 was discharged from the facility on 2/28/24. Review of the facility's McGeer's binder failed to show documented evidence the McGeer's assessments were conducted accurately to assess for true infection for the antibiotics prescribed for Residents 3 and 6. Further review showed Residents 3 and 6 had the McGeer's Criteria for Surveillance Checklist filled out showing the residents met the McGeer's Criteria, when in fact, the residents did not. Review of Resident 3's McGeer's Infection Surveillance record dated 1/10/24, showed Resident 3 only had one symptom checked for Pneumonia and one symptom checked for lower respiratory tract infection, which did not meet the McGeer's criteria; however, the assessment showed the McGeer's guidelines for true infection was met. Resident 3 was prescribed Invanz 1 gm vial IVPB QD for 7 days. In addition, another McGeer's Infection Surveillance record dated 1/10/24, showed Resident 3 only had one symptom checked for UTI, which did not meet the McGeer's criteria; however, the assessment showed the McGeer's guidelines for true infection was met. Resident 3's antibiotic order for UTI was also ordered as Invanz 1 gm IVPB QD for 7 days. Review of Resident 6's McGeer's Infection Surveillance record dated 1/9/24, showed Resident 6 only had two symptoms present for Pneumonia and two symptoms present for lower respiratory tract, which did not meet the McGeer's criteria; however the assessment showed the McGeer's guidelines for true infection was met. Resident 6 was prescribed Cefuroxime Axetil 500 mg one tab BID x 10 days. On 3/14/24 at 1018 hours, an interview and concurrent facility document review was conducted with the IP. The IP verified the criteria for true infection was not met for Residents 3 and 6. The IP stated the McGeer's tool was a data collection to see if a true infection was met, and it was a guideline for infections to prevent unnecessary antibiotic use.

MINOR (B)

Minor Issue - procedural, no safety impact

MDS Data Transmission (Tag F0640)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the MDS discharge assessment was completed for one nonsampled resident (Resident 26). This failure posed the risk for not being able to monitor the resident's decline and progress over time. Findings: Closed medical record review for Resident 26 was initiated on 3/11/24. Resident 26 was admitted to the facility on [DATE], and discharged home on [DATE]. Review of Resident 26's MDS discharge assessment dated [DATE], showed the facility failed to entered the data specific to section J0200 (Pain assessment interview) and the MDS discharge assessment dated [DATE], was subsequently rejected by the CMS system. On 3/14/24 at 1425 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON stated Resident 26 was discharged home on [DATE]. The DON verified Resident 26's MDS discharge assessment dated [DATE], was rejected. The DON reviewed Resident 26's rejected MDS discharge assessment dated [DATE], and determined the MDS discharge assessment was rejected as a result of the facility having failed to enter data specific to section J0200 (Pain assessment interview). The DON stated she would ensure the required data was added to the MDS discharge assessment and would then resubmit the MDS discharge assessment (to the CMS system).

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0655 (Tag F0655)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plan for one of two closed record sampled residents (Resident 27) was initiated upon admission. This failure had the potential for Resident 27 to not receive the necessary care and services in accordance with his care needs. Findings: Review of the facility's P&P titled Care Plan-Baseline revised 12/2016 showed to assure the resident's immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission. The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan. Closed medical record review for Resident 27 was initiated on [DATE]. Resident 27 was admitted to the facility on [DATE], and had expired on [DATE]. Review of Resident 27's closed medical record failed to show a baseline care plan was initiated for Resident 27. On [DATE] at 1358 hours, an interview and concurrent closed medical record review for Resident 27 was conducted with the DON. The DON verified the above findings. The DON verified Resident 27 did not have a baseline care plan. The DON stated the purpose of the baseline care plan was to ensure the basic needs of the residents are met. The DON further stated on admission, the admitting nurse was responsible for initiating the baseline care plan. On [DATE] at 1637 hours, the DON and Administrator were informed and acknowledged the above findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Garbage Disposal (Tag F0814)

Minor procedural issue · This affected multiple residents

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Based on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in one of one garbage dumpsters. This failure had the potential to attract the pest/rodents that carried diseases. Findings: According to the 2022 FDA (Food and Drug Administration) Food Code, outside garbage receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Review of the facility's P&P titled Food Related Garbage and Refuse Disposal revised 10/2017 showed the outside dumpsters provided by the garbage pickup services will be kept closed. On 3/11/24 at 0737 hours, an observation of the facility's outside garbage dumpster was conducted. The garbage dumpster was observed with the lid propped open by garbage preventing the lid from fully closing. On 3/11/24 at 1427 hours, an interview was conducted with Maintenance 1. Maintenance 1 verified the garbage dumpster was overflowing with garbage this morning, with the dumpster lid propped open with garbage. Maintenance 1 stated the trash company was scheduled to empty the garbage dumpster on Monday, Wednesday, and Friday.

May 2023 21 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 1) received the appropriate services needed to maintain acceptable parameters of nutritional status when: 1. The facility failed to implement the interventions to maintain Resident 1's nutritional status when Resident 1 experienced the following insidious weight loss (gradual, unintended, progressive weight loss over time): - 4 lbs, (3%) from 12/2/22 to 1/4/23, - 10 lbs (7%) from 10/3/22 to 1/4/23, and - 12 lbs (8%) from 8/5/22 to 1/4/22. 2. The facility failed to ensure the nutrition evaluations were performed by a qualified Registered Dietitian. 3. The facility failed to revise the resident-centered plan of care for Resident 1 to reflect the insidious weight loss from 8/5/22 to 1/4/23, and poor PO intake. These failures caused Resident 1 to experience severe weight loss of 11 pounds, 7.9% from 11/1/22 to 2/1/23; and severe weight loss of 16 pounds, 11% from 8/5/22 to 2/1/23. Findings: A professional reference review of the National Library of Medicine titled, An approach to the management of unintentional weight loss in elderly people, dated March 15, 2005, showed, Unintentional weight loss, or the involuntary decline in total body weight over time, is common among elderly people who live at home. Weight loss in elderly people can have a deleterious effect on the ability to function and on quality of life and is associated with an increase in mortality over a 12-month period .Unintentional weight loss is the involuntary decline in total body weight over time. In clinical practice, it is encountered in up to 8% of all adult outpatients and 27% of frail people 65 years and older. Weight loss is an important risk factor in elderly patients. It is associated with increased mortality, which can range from 9% to as high as 38% within 1 to 2.5 years after weight loss has occurred .Weight loss of 4%-5% or more of body weight within 1 year, or 10% or more over 5-10 years or longer, is associated with increased mortality or morbidity or both. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC552892/ A professional reference review of BSN (Balance Senior Nutrition) Solutions, titled, Weight Loss in the Elderly: When Should You Be Concerned? dated March 19, 2018, showed, According to the Centers for Medicaid and Medicare services (CMS), weight can be a useful indicator of nutritional status when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. Insidious weight loss refers to a gradual, unintended, progressive weight loss over time. https://www.bsnsolutions.net/weight-loss-in-the-elderly-when-should-you-be-concerned-clone#:~:text=%E2%80%9CInsidious%20weight%20loss%E2%80%9D%20refers%20to,progressive%20weight%20loss%20over%20time. A professional reference review of Dietetics in Healthcare Communities, a dietetic practice group of the American Dietetic Association titled Unintended Weight Loss in Older Adults: ADA Evidence Based Practice Guidelines dated 2011 showed, Most reference tables do not include elderly individuals in their subject pool, and thus these tables are not age adjusted. Standard height and weight tables and BMI tables are therefore not valid for use in older adults. https://higherlogicdownload.s3.amazonaws.com/THEACADEMY/4556f4af-bcea-4fd9-8fc9-5647e0d15658/UploadedImages/DHCC/Documents/UWL.pdf 1. Review of the facility's P&P titled Nutrition Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant, unplanned and undesired weight loss will be based on the follow criteria [where percentage of body weight loss = (usual weight - actual weight) / (usual weight) x 100: a. one month - 5% weight loss is significant; greater than 5% is severe, b. three months - 7.5% weight loss is significant; great than 7.5% is severe, c. six months - 10% weight loss is significant; greater than 10% is severe . Analysis 2. The Physician and multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk for weight loss . Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was readmitted to the facility on [DATE], with diagnoses including Non-ST elevation myocardial infarction (NSTEMI), a type of heart attack and muscle weakness. Review of Resident 1's Annual History and Physical Examination dated 4/11/23, showed Resident 1 could make needs known but could not make medical decisions. Review of Resident 1's Physician's Order dated 12/1/22 to 1/31/22, showed the orders dated 4/16/21, for Regular No Added Salt diet and multivitamin one tablet PO QD for supplement. Review of the facility's document titled Vital Signs Grid from 4/16/21 through 5/3/23, showed the following weights and comparisons for Resident 1: * On 12/2/22 = 136 lbs, -7 lbs, a 4.9% insidious weight loss in three months [comparison weight on 9/1/22, 143 lbs], * On 1/4/23 = 132 lbs, -4 lbs, a 3% insidious weight loss in one month [comparison weight on 12/2/22, 136 lbs]; -10 lbs, a 7% insidious weight loss in three months [comparison weight on 10/3/22, 142 lbs]; and -11 lbs, a 7.7% insidious weight loss in six months [comparison weight on 7/5/22, 143 lbs]. * On 2/1/23 = 128 lbs, -4 lbs, a 3% insidious weight loss in one month [comparison weight on 1/4/23, 132 lbs]; -11 lbs, an 8% severe weight loss in three months [comparison weight on 11/1/22, 139 lbs]; -16 lbs, a 11% severe weight loss in six months [comparison weight on 8/5/22, 144 lbs]. Review of the facility's document titled Resident Care Details dated 11/1/22 to 4/30/23, showed Resident 1's PO intake for the following months: * For the month of November 2022, 48% of the 89 meals recorded, the intake was less than or equal to 50% intake. * For the month of December 2022, 38% of the 90 meals recorded, the intake was less than or equal to 50% intake. * For the month of January 2023, 35% of the 88 meals recorded, the intake was less than or equal to 50% intake. Review of the facility's document titled Nutrition Evaluation completed by the Certified Dietary Manager on 8/24/22, showed Resident 1's weight on 8/19/22 was 144 lbs. The resident had no weight gain or loss, was not at risk for weight loss and dehydration, and was on a Regular NAS (No Added Salt) diet. The document also showed no recommendations at this time, no concerns, and continue to monitor monthly weights. The Nutrition Evaluation form did not include Resident 1's PO intake. Review of the facility's document titled Nutrition Evaluation completed by the Certified Dietary Manager on 12/1/22, showed Resident 1's weight on 11/1/22, was 139 lbs. The resident had no weight gain or loss, was at risk for weight loss and dehydration, and was on a Regular NAS diet. The document showed N/A for nutrition interventions/recommendations and to continue to monitor monthly weight and po intake. The Nutrition Evaluation form did not include Resident 1's PO intake. Review of the facility's document titled Departmental Notes- Dietary completed by the RDN on 12/14/22, showed the RD notes were for a follow up on the resident's PO intake. The note showed the following: weight: 136 lbs, BMI (body mass index) 22.6, and normal status. Resident 1 had three lbs weight loss for one month, seven lbs weight loss for three months, and six lbs weight loss for six months. Resident 1 had been showing variable, low PO intake. Resident 1 had variable PO intake with an average of 20-40-50-70% of all meals. Per the Certified Dietary Manager, Resident 1 refused to eat, notifying the nursing staff that she was not hungry. Dietary offered nutritional supplements, but the resident refused. The note showed a recommendation for appetite stimulant to improve PO intake; and would continue to monitor weights, labs, and PO intake. Review of the facility's document titled Nutritional Screening and Assessment - annual completed by the Certified Dietary Manager and RDN on 2/28/23, showed the current weight 128 lbs; IBWR (ideal body weight range) 121#--125#-138#; recent weight change: loss of 4 lbs in one month, loss of 11 lbs (8%) in three months, and loss of 16 lbs (11%) in six months. The document showed estimated calories needs for weight maintenance based on actual body weight 25-30 calories/kg (kilogram) 1450-1740 calories; and recommendation for four-ounce HPN (High Protein Nourishment) BID (twice a day) at lunch and dinner. Review of the facility's document titled Nursing Summary completed by LVN 4 on 12/14/22 at 2240 hours, showed the resident's weight was 136 lbs on 12/2/22, with excellent appetite and no changes in condition. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by RN 1 on 12/18/22 at 1028 hours, showed Resident 1 was on monitoring for poor PO intake, consumed 75% breakfast, and given fluid as tolerated. The note showed snacks offered in between meals .will continue to monitor. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/18/22 at 0807 hours, showed Resident 1 had an episode of poor PO intake during dinner, consumed 30% of dinner. The note showed alternate offered and refused .will continue to monitor. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 6 on 12/18/22 at 0724 hours, showed for Resident 1 to continue monitoring for low appetite. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 5 on 12/19/22 at 1230 hours, showed in part, decreased appetite, ate 20% of breakfast and 30% of lunch, and when encouraged to eat, the resident became agitated and began to ramble and say things not pertaining to meal. When redirected, the resident stated, I don't want to eat or I can't eat or I don't like this food. When asked what meal she preferred or what other food she would like to eat, the resident said nothing or yelled to leave her alone. Provided food that the family said she liked, but the resident also refused the meals. The note showed encouraged supplements and fluids as the resident could tolerate. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/19/22 at 2257 hours, showed no episode of poor PO intake during dinner and consumed 100% of dinner. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by the DSD/IP on 12/20/22 at 1103 hours, showed in part, the physician ordered CBC (complete blood count), CMP (complete metabolic panel), UA (urinalysis)/c+s (culture plus sensitivity). Review of the facility's document titled Departmental Notes- General Nurses Notes completed by LVN 4 on 12/20/22 at 1939 hours, showed the resident consumed 50% of dinner, alternate was offered and refused, and fluids were encouraged and offered as tolerated. Review of the facility's document titled Departmental Notes- General Nurses Notes completed by the DON on 2/3/23 at 2217 hours, showed Resident 1's weight was reviewed and the resident 's weight loss for six months. Resident 1 had a declining appetite. Physician 1 was made aware of the IDT recommendations for weekly weights, RD consult, fortify diet, and four-ounce HPN BID between meals; and agreed. Review of the facility's document titled Weight Variance Committee for Resident 1 dated 2/3/23, showed the following IDT members were present: the Certified Dietary Manager, DON, and SSD. The RDN was not present. The note showed the resident's average meal intake for breakfast, lunch, and dinner was 25-50%. The current weight was 128 lbs and BMI <22, and the identified weight trend was documented as -16 lbs x 6 months, with the known or suspected cause of decreased appetite. The current interventions was documented as none, and the physician and responsible party were notified on 2/3/23. Review of Resident 1's Physician Progress Notes dated 10/7/22, showed Resident 1's weight was 143 lbs, and to continue with the current orders. Review of Resident 1's Physician Progress Note dated 11/7/22, showed Resident 1 was doing fair and ate ok, and to continue with the current treatment. Review of Resident 1's Physician Progress Note dated 12/9/22, showed Resident 1 was alert, and to continue with the current medications. Review of Resident 1's Physician Progress Note dated 1/20/23, showed Resident 1 was awake but confused on and off, and to continue with the present plan. Review of Resident 1's Physician Progress Note dated 2/5/23, showed Resident 1 was doing fair, except more forgetful. The document showed oral intake fair, weight 128 lbs, and to continue with the current treatment. During the lunch meal dining observation on 5/02/23 at 1208 hours, Resident 1 was observed sitting in the resident dining room with two other residents at the table. Resident 1 appeared thin, confused, and was not eating her lunch. Resident 1 was asked why she was not eating, she replied, I have too much at home. The DSD then asked Resident 1 if she wanted something else to eat but Resident 1 refused a meal alternative. Resident 1 consumed four ounces of juice and four ounces of HPN. On 5/2/23 at 1513 hours, Resident 1 was observed in the hallway sitting in her wheelchair drinking four ounces of HPN. On 5/02/23 at 1400 hours, an interview was conducted with the RDN. The RDN was asked to explain the resident weight loss protocol for the facility. The RDN stated significant weight loss of 5% in a month, 7.5% in three months, and 10% in six months were reviewed. The RDN talked to the DON but was not part of the IDT weight variance meeting. The RDN stated she was not involved in creating or revising the resident's care plans. On 5/3/23 at 1539 hours, an electronic medical review of Resident 1 and concurrent interview was conducted with the DON. The DON was asked to explain the resident's weight loss protocol for the facility. The DON explained the residents with significant weight loss of 5% in a month, 7.5% in three months, and 10% weight loss in six months were followed in the IDT weight variance committee. The nurses were responsible to notify the physician and resident's responsible party of any significant weight change. The DON stated the IDT weight variance committee included herself, the Certified Dietary Manager, and social service. The RDN was not part of the IDT weight variance committee, but the RDN asked the Certified Dietary Manager or DON about any residents with changes. The DON stated the RDN completed a report after each visit with recommendations. The DON and nursing received a copy of the RDN weekly report and recommendations. The charge nurse was responsible to notify the physician of the RDN's recommendations and write an order. If the physician did not agree with the RDN's recommendation, the charge nurse should document such in the resident's medical record. The DON was asked how the facility handled the residents with insidious weight loss. The DON stated if the residents experienced insidious weight loss, the IDT would intervene with the same protocol as significant weight loss. The DON was asked about Resident 1's weight loss. The DON stated Resident 1 was currently being followed in the IDT weight variance committee. The DON confirmed Resident 1 was first reviewed by the IDT weight variance committee on 2/3/23, due to a significant weight loss of 16 lbs in six months. The DON was asked who was responsible for weight change calculations. The DON stated the RDN calculated weight changes, but she could also run a report. Resident 1's weight report was reviewed with the DON. The DON confirmed Resident 1 had insidious weight loss of four lbs (3%) from 12/2/22 to 1/4/23, 10 lbs (7%) from 10/3/22 to 1/4/23, and 12 lbs (8%) from 8/5/22 to 1/4/22. The DON confirmed Resident 1's insidious weight loss between 1/4/23 and 8/5/23 was not discussed in the IDT weight variance committee. When asked what the facility's criteria to follow a resident with insidious weight loss was, the DON stated if the resident became underweight. The DON was asked if a resident with poor PO intake would be followed in the IDT weight variance committee. The DON confirmed if a resident had poor PO intake that would be addressed in the IDT weight variance committee. The DON was asked to review Resident 1`s medical record during the month of December when Resident 1 experienced insidious weight loss and poor PO intake. The DON stated on 12/14/22, the RDN wrote a note that addressed Resident 1's insidious weight loss and poor PO intake. The DON acknowledged on 12/14/22, the RDN recommended an appetite stimulant for Resident 1. The DON confirmed there was no note from nursing showing the physician was contacted regarding the RDN's recommendation for an appetite stimulant. The DON confirmed the RDN recommendations should be completed within 72 hours of receiving the recommendations. The DON was asked how she was notified of the RDN recommendations. The DON stated she received a paper copy of the RDN's report and recommendations. The DON was asked how she ensured the RDN recommendations were completed. The DON stated the nursing usually put the completed RDN recommendations under the door of her office, but the DON had discarded the completed RDN recommendations. The DON stated she only kept the original RDN recommendation reports. The DON was not able to confirm she received any RDN recommendation reports from December 2022. The DON stated she did not remember seeing the RDN in December 2022 and thought the RDN had worked virtually. The DON stated on 12/18/22, Resident 1 was on a change of condition (COC) monitoring due to poor intake. The DON stated the facility's procedure for a COC did not include a change of condition form, and the nursing staff was only required to monitor the resident for 72 hours. The DON stated the nursing staff was responsible to notify the physician and resident responsible party of any change of condition. The DON confirmed there was no note showing the physician or Resident 1's responsible party were notified of Resident 1's poor intake. The DON stated on 12/20/22, the physician ordered a lab work for Resident 1, therefore, the nursing staff must have notified the physician of Resident 1's poor po intake. The DON was asked if any other interventions such as weekly weight monitoring were implemented for Resident 1 in December 2022. The DON confirmed no interventions to mitigate Resident 1's weight loss or poor intake was added for Resident 1 in December 2022. The DON confirmed Resident 1 was discussed in the IDT meeting on 2/3/23, related to a severe weight loss of 16 lbs, 11% since 8/5/22, due to declining appetite. The IDT recommended weekly weights, RD consult, fortify diet, four-ounce HPN (high protein nourishment) twice a day between meals. The DON acknowledged waiting until 2/3/23, to address Resident 1's weight loss with the IDT was not timely. The DON confirmed the RDN did not re-evaluate Resident 1 since 12/14/22. The DON confirmed the next RDN evaluation was completed on 2/28/23. The DON acknowledged waiting until 2/28/23, more than two months after Resident 1 began losing weight and since the previous RD evaluation on 12/14/22, was not considered timely. On 5/4/23 at 1321 hours, a telephone interview was conducted with the RDN. The RDN was asked the facility process with monthly weights. The RDN stated she obtained a paper copy of the monthly weights from the weight book. The RDN calculated significant weight changes of 5% in a month, 7.5% in three months, and 10% in six months. She stated she only addressed significant weight change. The RDN wrote her recommendations on a paper form and gave a copy to the DON. When asked if only residents with weight loss were discussed in the weight variance committee, the RDN stated she was not sure what residents were discussed since she did not attend the weight variance committee meeting. The RDN was asked how she ensured her recommendations were completed. The RDN stated if the resident came back on her radar, she would follow up on her recommendations. The RDN confirmed she had no system to ensure her recommendations were completed. The RDN further stated she did not check to see if the nursing had completed her recommendations. The RDN was asked how she was notified of a resident with poor PO intake. The RDN stated the CDM would either tell her verbally or write a note in the RD binder. Resident 1's electronic medical record was reviewed with the RDN. The RDN acknowledged she wrote a note on 12/14/22, for Resident 1 regarding poor PO intake and gradual weight loss. The RDN acknowledged she recommended an appetite stimulant for Resident 1. The RDN stated she could not recall if she worked virtually in December or on site. The RDN stated if she worked virtually, she would take a picture of her recommendations and text it to the DON or call the DON and relay her recommendations. The RDN was asked if she documented she called or texted the DON with her recommendation. The RDN stated she did not document how her recommendations were communicated to the DON in December 2022. The RDN confirmed she did not have a system how to communicate the recommendations for the residents when she was working virtually. The RDN was asked what other interventions she would consider if a resident was not eating. The RDN agreed that weekly weights should have been recommended for Resident 1 in December. The RDN then stated the weekly weights were only recommended for those residents who had experienced significant weight loss. The RDN was asked if she was familiar with the term insidious weight loss. The RDN was not familiar with the term insidious weight loss but agreed that unplanned weight loss whether significant or gradual was not desirable in the elderly population. The RDN was asked when the next nutrition assessment was completed for Resident 1. The RDN stated an annual nutrition assessment was completed on 2/28/23. The RDN was asked when she received the resident monthly weights. The RDN stated she received the resident monthly weights during the first week of each month. The RDN acknowledged waiting until 2/28/23, to assess Resident 1's severe weight loss of 11 lbs, 7.9% in three months and 16 lbs, 11% in six months was not ideal. On 5/4/23 at 1546 hours, a follow-up interview was conducted with the DON. The DON was asked if she received a picture the RDN's recommendations in December via text message or email from the RDN. The DON confirmed after checking her emails and phone records, she did not receive the recommendations from the RDN. The DON further confirmed the RDN recommendations she had were from 11/29/22 to 1/3/23, the DON stated she had no other RDN recommendations between those dates. On 5/5/23 at 1035 hours, a telephone interview was conducted Physician 1. Physician 1 declined to discuss Resident 1 and stated he was on an airplane. On 5/5/23 at 1048 hours, an interview was conducted with Resident 1's family member. Resident 1's family member stated they were aware the resident had lost weight and had not been eating well for about six months. 2. Review of the facility's P&P titled Nutrition Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. Review of the facility document titled Director, Nutritional Services Job Description signed and dated by the Certified Dietary Manager on 9/12/16, showed to ensures the timely preparation and delivery of nutritious and attractive meals and supplements to all residents according to physician order and in compliance with Federal, State and company requirements; maintains a safe and sanitary working environment; ensures that meals are served according to expressed resident preferences; plan, implements and revises menus to meet resident needs; and interacts effectively with other resident services according to total care plan approach. Review of the electronic medical record for Resident 1 and concurrent telephone interview was conducted with the RDN on 5/04/23 at 1321 hours. The RDN confirmed the Certified Dietary Manager completed the quarterly nutrition evaluations for all residents. The quarterly nutrition evaluation for Resident 1 dated 12/1/22, was reviewed with the RDN. The RDN confirmed the quarterly nutrition evaluation showed Resident 1's weight of 139 lbs was from 11/1/22. The RDN confirmed the quarterly nutrition evaluation showed Resident 1 had not lost weight, was not at weight loss and dehydrations risks, and did not have any nutrition interventions/recommendations; and to continue to monitor monthly weights and po intake. The RDN agreed the 12/2/22 weight of 136 should have been included in the December quarterly nutrition evaluation and the insidious weight loss of seven lbs (6%) from 9/1/22 to 12/2/22, should have been addressed in the quarterly nutrition evaluation. The RDN further agreed that Resident 1 was at risk for weight loss and dehydration due to poor PO intake. The RDN confirmed the nutrition evaluation form did not include the residents' PO intake. The RDN was asked if she reviewed the quarterly nutrition evaluations that were completed by the Certified Dietary Manager. The RDN confirmed she did not review the quarterly nutrition evaluations completed by the Certified Dietary Manager. The RDN further stated she was not aware the CDM was not a qualified individual to perform nutrition evaluations. On 5/5/23 at 1331 hours, an interview was conducted with the Administrator. The Administrator was not aware a Certified Dietary Manager was not qualified to complete the resident assessments. The Administrator was not aware of the California business and professions code 2586 which stated the RD was the professional permitted to conduct medical nutrition therapy which includes assessment, determination of nutrition diagnosis and recommendation and implementation of nutrition care and intervention. The Administrator agreed the RD should be cosigning or completing the quarterly nutrition evaluations. Cross reference to F836. 3. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed in part, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, 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 the resident's legal surrogate. 2. Individualized care plans will address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Timeframes and parameters for monitoring and reassessment. On 5/3/23 at 1539 hours, a review of Resident 1's electronic medical record and concurrent interview was conducted with the DON. The DON stated the nursing staff was responsible for the resident's care plans. The DON confirmed Resident 1's poor intake in December and insidious weight loss from 8/5/22 to 1/4/23, had not been added to Resident 1's care plan but should have been added. On 5/4/23 at 1321 hours an interview was conducted with the RDN. The RDN stated she was not involved in resident care planning. Cross reference to F657.

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medications were safely administered to one of 14 final sampled residents (Resident 729) and one nonsampled resident (Resident 25). * Resident 729 had the Biofreeze gel (cooling menthol used to provide temporary pain relief) and Cool n' Heat roll on (topical liquid to help relieve minor aches and pains) at the bedside. Resident 729 did not have a physician's order to keep these medications at the bedside. * Resident 25 had the TheraHoney wound gel (healing gel used to speed up the healing of burns and wounds) at the bedside. Resident 25 did not have a physician's order to keep the medication at the bedside. These failures had the potential to negatively impact Residents 729 and 25's physiological well-being. Findings: Review of the facility's P&P titled Self-Administration of Medications revised February 2021 showed the residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy also showed self-administered medications are stored in a safe and secure place, which is not accessible by other residents. a. On 5/2/23 at 0812 hours, an observation and concurrent interview was conducted with Resident 729. Resident 729 was observed with the Biofreeze gel tube and Cool n' Heat roll on bottle at bedside. Resident 729 stated she applied the gel and roll on to her neck, shoulders, and hips for pain. Resident 729 stated the facility staff also helped her apply the gel and roll on to her back for pain. Resident 729 stated she had been self-administering the medications over a week and the nurses were aware. On 5/3/23 at 0746 hours, an observation and concurrent interview was conducted with Resident 729. Resident 729 was observed with the Biofreeze gel tube and Cool n' Heat roll on bottle at bedside. Resident 729 stated the physical therapist helped her applying them to her back for pain after her therapy sessions. Medical record review for Resident 729 was initiated on 5/2/23. Resident 729 was admitted to the facility on [DATE]. Review of Resident 729's H&P examination dated 4/11/23, showed Resident 729 had the capacity to understand and make decisions. Review of the Self-Administration of Medications assessment dated [DATE], showed Resident 729 did not have evidence of cognitive and/or functional ability to safely self-administer medications. Review of Resident 729's physician's orders failed to show the orders for the Biofreeze gel, Cool n' Heat roll on and self-administration of these medications. Review of Resident 729's plan of care failed to show a care plan problem was initiated or developed to address the resident's self-administration of the medications. On 5/3/23 at 0800 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 729 had the Biofreeze gel tube and Cool n' Heat roll on bottle at the bedside. LVN 1 stated she was not aware Resident 729 had the Biofreeze gel and Cool n' Heat roll on at bedside. LVN 1 stated Resident 729 could not have the medications at bedside. On 5/3/23 at 1154 hours, an interview was conducted with the CQA/IP. The CQA/IP verified Resident 729 did not have the physician's orders for the Biofreeze gel, Cool n' Heat roll, on and self-administering the medications. The CQA/IP verified Resident 729 did not have a care plan for self-administration of the medications. The CQA/IP stated Resident 729 should not have kept the medications at the bedside. On 5/4/23 at 0842 hours, an interview was conducted with the PTA. The PTA stated she applied the Biofreeze gel and Cool n' Heat roll on to Resident 729's back before and after the resident's therapy session when Resident 729 requested for it. The PTA stated she did not inform the nurses because the Biofreeze and Cool n' Heat roll on were over the counter items and she did not consider them as medications. On 5/5/23 at 1139 hours, an interview was conducted with the Pharmacist. The Pharmacist stated the Biofreeze gel and Cool n' Heat roll on contained menthol, which considered as a medication. On 5/4/23 at 1325 hours, an interview was conducted with the DON. The DON verified Residents 729 did not have the physician's order and care plan problem addressing the self-administration of the medications. b. On 5/2/23 at 0833 hours, an observation and concurrent interview was conducted with Resident 25. Resident 25 was observed with the TheraHoney wound gel at the bedside. Resident 25 stated the facility staff helped her apply the wound gel to her legs. On 5/3/23 at 0755 hours, an observation was conducted with Resident 25. Resident 25 was observed with the TheraHoney wound gel at the bedside. Medical record review for Resident 25 was initiated on 5/2/23. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 3/11/23, showed Resident 25 had the capacity to understand and make decisions. Review of the Self-Administration of Medications assessment dated [DATE], showed the resident did not have evidence of cognitive and/or functional ability to safely self-administer medications. Review of Resident 25's physician's orders failed to show an order for the TheraHoney wound gel and self-administration of the medication. Review of Resident 25's plan of care failed to show a care plan problem was initiated or developed for the resident's self-administrations of medications. On 5/3/23 at 0816 hours, an observation and concurrent interview was conducted with the DSD/IP. The DSD/IP verified Resident 25 had the TheraHoney wound gel at the bedside. The DSD/IP stated the TheraHoney wound gel was considered a medication and should not be at the bedside. The DSD/IP was observed removing the TheraHoney wound gel from Resident 25's bedside. On 5/3/23 at 1135 hours, a follow-up interview was conducted with the DSD/IP. The DSD/IP verified Resident 25 did not have a physician's orders for TheraHoney wound gel and self-administer the medication. The DSD/IP verified Resident 25 did not have a care plan for self-administration of the medications and Resident 25's Self-Administration of Medications Assessment showed she did not have the ability to safely self-administer medications. On 5/4/23 at 1325 hours, an interview was conducted with the DON. The DON verified Residents 25 did not have the physician's order and care plan problem addressing the self-administration of medications.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide information regarding the rights to formulate the advance directives (legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions) to four of 14 final sampled residents (Residents 5, 21, 24, and 729) and one nonsampled resident (Resident 25). This failure had the potential for the residents' wishes related to the provision of medical treatment and services to not be followed if the residents were unable to make medical decisions for themselves. Findings: Review of the facility's P&P titled Advance Directives dated December 2016 showed the resident will be 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 upon admission. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 1. Medical record review for Resident 25 was conducted on 5/2/23. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 3/11/23, showed Resident 25 had the capacity to understand and make decisions. Review of the POLST dated 3/13/23, under Section D, showed Resident 25 had no advance directive. The POLST did not show the advance directive was offered and discussed with Resident 25. Further review of Resident 25's medical record did not show the information was provided to Resident 25 for the formulation of advance directive. On 5/3/23 at 1405 hours, a concurrent interview and record review was conducted with the SSD. The SSD verified there was no documentation to show information on the formulation of advance directive was offered to Resident 25. The SSD stated the advance directive information should have been offered to Resident 25 and the discussion should have been documented in Resident 25's medical records. 2. Medical record review for Resident 729 was initiated on 5/2/23. Resident 729 was admitted to the facility on [DATE]. Review of Resident 729's H&P examination dated 4/11/23, showed Resident 729 had the capacity to understand and make decisions. Review of the POLST dated 4/11/23, under Section D, showed Resident 729 had no advance directive. The POLST did not show the advance directive was offered and discussed with Resident 729. Further review of Resident 729's medical record did not show the information was provided to Resident 729 for the formulation of advance directive. On 5/3/23 at 1401 hours, a concurrent interview and record review was conducted with the SSD. The SSD was made aware and verified the above findings. The SSD stated the advance directive information should have been offered to Resident 729 and the discussion should have been documented in Resident 729's medical records. 3. Medical record review for Resident 24 was initiated on 5/2/23. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's H&P examination dated 2/5/23, showed Resident 24 could make needs known but could not make medical decisions. Review of the POLST dated 2/3/23, under Section D, showed Resident 24 had no advance directive. The POLST did not show the advance directive was offered and discussed with Resident 24 and/or his responsible party. Review of Resident 24's IDT Conference Note dated 2/6/23, showed Resident 24 did not have an advance directive. The note did not show information was provided to Resident 24 or his responsible party for the formulation of advance directive. On 5/3/23 at 1035 hours, an interview was conducted with Resident 24. Resident 24 stated he was aware what an advance directive was, however, he did not remember whether he was offered information to formulate an advance directive at the facility. 4. Medical record review for Resident 5 was initiated on 5/2/23. Resident 5 was readmitted to the facility on [DATE]. Review of Resident 5's POLST signed on 2/22/23, showed Resident 5 had no advanced directive. On 5/2/23 at 1341 hours, an interview and concurrent medical record review was conducted with the SSD. When asked about the process for the resident's advanced directives, the SSD stated she provided the residents with the advanced directive literature and Advanced Directive Acknowledgement Form. The SSD further stated the advanced directive was discussed with the resident every care plan meeting. When asked if Resident 5 had an advanced directive, she stated Resident 5 did not had an advanced directive or Advanced Directive Acknowledgment Form. On 5/3/23 at 1600 hours, a follow-up interview was conducted with the SSD. When asked if she had any documentation to show she provided the advanced directive literature to Resident 5 or his responsible party, the SSD stated she did not have documentation regarding Resident 5's advanced directive. 5. Medical record review for Resident 21 was initiated on 5/2/23. Resident 5 was admitted to the facility on [DATE]. Review of Resident 21's POLST prepared on 11/21/22, showed Resident 21 did not have an advanced directive. On 5/2/23 at 1341 hours, an interview and concurrent medical record review was conducted with the SSD. When asked about the process for advanced directives, the SSD stated she provided the residents with the advanced directive literature and Advanced Directive Acknowledgement Form. The SSD further stated the advanced directive was discussed with the resident every care plan meeting. When asked if Resident 21 had an advanced directive, the SSD stated Resident 21 did not had an advanced directive or Advanced Directive Acknowledgment Form. On 5/3/23 at 1600 hours, a follow-up interview was conducted with the SSD. When asked if she had any documentation to show she provided advanced directive literature to Resident 21 or resident's responsible party, the SSD stated she did not have documentation regarding Resident 21's advanced directive. On 5/5/23 at 1500 hours, the Administrator, DON, CQA/IP Nurse, and SSD were informed and acknowledged the above findings.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to exercise reasonable care for the protection property from loss for one of 14 final sampled residents (Resident 729). Resident 729's two shirts were lost in the facility. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Personal Property revised September 2012 showed the facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. Review of the facility's P&P titled Grievances/Complaints, Recording and Investigating dated April 2017 showed all grievances and complaints filed with the facility will be investigated and corrective actions will be taken to resolve the grievances. On 5/2/23 at 0812 hours, an interview was conducted with Resident 729. Resident 729 stated three shirts were brought to the facility's laundry by a staff member; however, only one shirt was brought back to her room after it was laundered. Resident 729 further stated she had lost two shirts and the facility staff were aware. Medical record review for Resident 729 was initiated on 5/2/23. Resident 729 was admitted to the facility on [DATE]. Review of Resident 729's H&P examination dated 4/11/23, showed Resident 729 had the capacity to understand and make decisions. Review of Resident 719's Inventory of Personal Effects dated 4/12/23, showed Resident 729 had four shirts/blouses upon admission to the facility. On 5/3/23 at 1132 hours, an interview was conducted with the DSD/IP. When asked about the facility's protocol regarding the residents' complaint of lost items, the DSD/IP stated the facility should look for the missing items and if the missing items were not found, the complaint should be reported to the SSD as a theft and loss. On 5/3/23 at 1425 hours, an interview was conducted with the SSD. The SSD verified Resident 729's Inventory of Personal Effects form included four shirts/blouses. The SSD stated she was not aware of Resident 729's missing shirts and the facility staff did not report to her about Resident 729's missing shirts. On 5/4/23 0932 hours, a follow-up interview was conducted with Resident 729. Resident 729 stated she lost one black and one white shirt. Resident 729 further stated the other shirts had thin straps. Resident 729 stated she could not remember the staff who she had complained to about her lost shirts. Resident 729 further stated the facility never found her two shirts and never replaced them. On 5/4/23 at 0942 hours, an interview was conducted with CNA 3. CNA 3 stated she recalled Resident 729 had complained about losing three shirts; however, CNA 3 could not recall when it occurred. CNA 3 stated one shirt was found in the laundry room and Resident 729's family member confirmed the shirt was Resident 729's missing shirt. CNA 3 further stated she informed the DSD about the two other missing shirts. On 5/4/23 at 0946 hours, a follow-up interview was conducted with the DSD/IP. The DSD/IP stated she recalled CNA 3 reporting to her about Resident 729's two missing shirts; however, the DSD/IP did not file a grievance or report the complaint to the SSD because she thought all three missing shirts were found. The DSD/IP further stated she was not aware that only one of the shirts was found. The DSD/IP stated she did not follow-up with Resident 729 to verify whether her complaint was resolved.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interview, medical record review, and facility P&P review, the facility failed to ensure the resident-centered care plan for one of 14 final sampled residents (Resident 1) was revised to reflect the resident's poor oral intake and insidious weight loss (gradual, unintended, progressive weight loss over time) of - 4 lbs, (3%) from 12/2/2022 to 1/4/2023, - 10 lbs (7%) from 10/3/2022 to 1/4/2023, and - 12 lbs (8%) from 8/5/2022 to 1/4/2022. This failure caused Resident 1 to not receive the necessary care needed to maintain acceptable parameters of nutritional status. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed in part, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of the facility's P&P titled Weight Assessment and Intervention undated showed in part, 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 the resident's legal surrogate. 2. Individualized care plans will address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Timeframes and parameters for monitoring and reassessment. On 5/3/23 at 1539 hours, a review of Resident 1's electronic medical record and concurrent interview was conducted with the DON. The DON stated the nursing staff was responsible for the resident's care plans. The DON confirmed Resident 1's poor intake in December and insidious weight loss from 8/5/22 to 1/4/23, had not been added to Resident 1's care plan but should have been added. On 5/4/23 at 1321 hours, an interview was conducted with the RDN. The RDN stated she was not involved in resident care planning. Cross reference to F802, example #3.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Pacemaker, Care of a Resident revised December 2015 showed to monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmia (an abnormally slow resting heart rate). Under the section for Documentation, the policy showed for each resident with a pacemaker, to document the following in the medical record and on a pacemaker identification card upon admission: - The name, address, and telephone number of the cardiologist; - Type of pacemaker; - Type of leads; - Manufacturer and model; - Serial number; - date of implant; and - Paced rate. Review of the manufacturer's instruction titled First Steps: How Do I Use the CardioMessenger showed to check the pacemaker transmitter once a day whether the transmitter is powered on and ready for use, which is indicated by a OK icon displayed on the screen. Medical record review for Resident 15 was initiated on 5/2/23. Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 1/15/23, showed Resident 15 was able to make needs known but could not make medical decisions. The document showed Resident 15 had ASCVD with a permanent pacemaker and hypertension. Review of Resident 15's plan of care showed a care plan problem titled Risk for pacemaker malfunction dated 1/19/23. The interventions included to monitor and notify Resident 15's physician when the resident's pulse was below 60 beats per minute and/or when the resident became symptomatic (shortness of breath, chest pain, dizziness, altered level of consciousness, or hypotension). Review of Resident 15's Order Summary Report failed to show the physician's orders to monitor Resident 15's pulse and symptoms of pacemaker malfunction. Further review of Resident 15's medical record did not show information related to Resident 15's pacemaker or pacemaker transmitter. On 5/4/23 at 0951 hours, a concurrent interview and record review was conducted with the DSD/IP. The DSD/IP stated she was aware Resident 15 had a pacemaker and a pacemaker transmitter. The DSD/IP stated a copy of Resident 15's pacemaker card was in the medical record; however, Resident 15's pacemaker information was not documented in the medical records. The DSD/IP verified Resident 15 did not have the physician's orders to monitor her pulse. The DSD/IP stated Resident 15's pulse should be monitored and documented. On 5/4/23 at 1002 hours, an observation and concurrent follow-up interview was conducted with the DSD/IP. Resident 15's CardioMessenger Smart Transmitter (pacemaker transmitter) was observed on top of the overhead light with its charger cord plugged into the wall outlet. The DSD/IP was observed moving the pacemaker transmitter to Resident 15's bedside table. The pacemaker transmitter was observed with an OK icon displayed on the screen. The DSD/IP stated the pacemaker transmitter should be checked every shift by the licensed nurse to ensure an OK icon displayed on the screen and was ready for use. When asked how the licensed nurses were aware to check the pacemaker transmitter, the DSD/IP stated a physician's order should be in Resident 15's medical record to ensure the licensed nurses checked the pacemaker transmitter. The DSD/IP verified Resident 15 did not have a physician's order to monitor the pacemaker transmitter. On 5/5/23 at 1104 hours, an interview was conducted with LVN 2. LVN 2 stated she was aware Resident 15 had a pacemaker; however, LVN 2 stated she was not aware Resident 15 had a pacemaker transmitter. When asked how LVN 2 checked if Resident 15's pacemaker was functioning properly, LVN 2 stated she checked Resident 15's apical pulse during the administration of her blood pressure medication. LVN 2 stated she documented Resident 15's pulse in the electronic MAR, under the monitoring section for Resident 15's blood pressure medication. LVN 2 stated she did not know how the pacemaker transmitter functioned and what she needed to do with the pacemaker transmitter. LVN 2 stated she had not been provided education or in-services about Resident 15's pacemaker transmitter. On 5/4/23 at 1321 hours, a concurrent interview and record review was conducted with the DON. The DON verified Resident 15 had the pacemaker and pacemaker transmitter. The DON stated a copy of Resident 15's pacemaker card was in the medical record; however, the information was not documented in Resident 15's medical record. The DON verified Resident 15 did not have physician's orders to monitor her pulse and to monitor the pacemaker transmitter. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 14 final sampled residents (Residents 1 and 15) were provided quality care when: * The facility did not notify the physician or the resident's responsible party about Resident 1's change of condition regarding the resident's low blood pressure. This failure had the potential to cause harm to Resident 1. * Resident 15 had a permanent pacemaker (implanted electronic device in the chest to help control the heartbeat) with a pacemaker transmitter (allows information from the implanted device to be sent to the doctor) at the bedside. The facility failed to ensure the information related to Resident 15's pacemaker was documented in the medical record. The pulse for Resident 15's pacemaker was not monitored and recorded. Resident 15's pacemaker transmitter was not monitored routinely. This had the potential for Resident 15 to not receive the appropriate care and services to treat her medical conditions. Findings: 1. Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 showed the nurse will notify the resident's physician when there has been a significant change in the condition of a resident, which includes any status that does not resolve itself without intervention by staff. Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 1 had the diagnosis of hypertension (high blood pressure) and history of falls. Review of Resident 1's physician's orders showed the following two orders for metoprolol (antihypertensive) medication: - metoprolol tartrate 50 mg one tablet by mouth twice a day for hypertension; hold if systolic blood pressure less than 110 mmHg, heart rate less than 60 beats per minute, to be taken with food; and this order was started on 4/13/23 and discontinued on 5/3/23. - metoprolol tartrate 50 mg one tablet by mouth twice a day for hypertension; hold if systolic blood pressure less than 110 mmHg, heart rate less than 60 beats per minute; and this order was started on 4/21/23 and discontinued on 5/2/23. Review of Resident 1's MAR for April and May 2023 showed Resident 1 received metoprolol tartrate 50 mg on the following dates and times: - At 0700 hours from 4/14 to 5/3/23 - At 0900 hours from 4/1 to 4/7, 4/9, 4/11 to 4/17, 4/20 to 4/23, and 4/25 to 5/2/23 - At 1700 hours from 4/1 to 4/18, 4/20 to 4/27, and 4/29 to 5/2/23 Further review of Resident 1's MAR for April 2023 showed the following blood pressure readings: - On 4/19/23, 81/63 mmHg - On 4/24/23, 96/56 mmHg - On 4/28/23, 73/67 mmHg Review of Resident 1's Progress Notes for April 2023 showed no documented evidence Resident 1's physician and responsible party or family member were notified of Resident 1's low blood pressure readings. On 5/4/23 at 0907 hours, an interview was conducted with the DSD/IP. When asked about the facility's change of condition policy, she stated a change of condition was defined when something happens to a resident that was not within the resident's baseline. She further stated if a change of condition occurred, the charge nurse should contact the resident's provider and family member. When asked where a change in condition would be documented, she stated the nurse should document the resident's status and blood pressure in the progress notes. On 5/4/23 at 1333 hours, an interview was conducted with LVN 1. When asked what the process was if a resident had a low blood pressure reading, LVN 1 stated she would review the resident's ordered medications, provide interventions, and recheck the blood pressure. When asked about Resident 1's blood pressure reading of 96/56 mmHg on 4/24/23, she stated she elevated Resident 1's legs, which resolved the blood pressure after 30 minutes. When asked if she documented a change of condition for the resident, she stated she did not document a change of condition since Resident 1's blood pressure improved after 30 minutes. On 5/4/23 at 1425 hours, an interview and concurrent medical record review was conducted with the DON. When asked what the protocol was for a resident with low blood pressure, the DON stated she expected her staff to notify the physician and monitor the resident more frequently. Upon review of the blood pressure readings of 81/63 mmHg (4/19/23), 96/56 mmHg (4/24/23), and 73/67 mmHg (4/28/23), she stated those readings would be considered a change of condition for the resident. She would expect the nurse to notify the physician, monitor the resident, and document their interventions in the progress notes. On 5/5/23 at 1530 hours, the Administrator, DON, and CQA/IP were informed and acknowledged the above findings. Cross reference to F760.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for two of 14 final sampled residents (Residents 9 and 22). * The facility failed to follow the physician's order for Resident 22's oxygen therapy. This posed the risk for Resident 22 to develop complications related to oxygen use. * The facility failed to ensure Residents 9 and 22's nasal cannula tubings were dated as per the facility's P&P. This had the potential for increased risks of infection. Findings: 1. Review of the facility's P&P titled Administering Medications revised 4/2019 showed medications are administered in a safe, timely manner, and as prescribed. On 5/3/23 at 0813 hours, during an observation, Resident 22 was observed sitting in her wheelchair using oxygen via nasal cannula which was attached to the oxygen machine setting at 3 liters per minute. Medical record review for Resident 22 was initiated on 5/3/23. Resident 22 was readmitted to the facility on [DATE], with diagnosis of COPD. Review of Resident 22's Order Summary Report dated May 2023 showed a physician's order dated 12/5/22, for oxygen administration at 2 liters per minute via nasal cannula (medical device to provide supplemental oxygen therapy) as needed for shortness of breath and to keep the oxygen saturation level greater than 92%. Review of Resident 22's care plan dated 12/5/22, showed to administer oxygen as ordered. On 5/3/23 at 0813 hours, an observation, interview, and concurrent medical record review was conducted with LVN 1. LVN 1 verified the oxygen machine was set at 3 liters per minute and the physician's order for the oxygen was administered at 2 liters per minute as needed for Resident 22. LVN 1 checked for Resident 22's oxygen saturation level. LVN 1 stated Resident 22's oxygen saturation level was 98%. LVN 1 removed Resident 22's oxygen tubing and stated Resident 22 did not need oxygen at that time because Resident 22's oxygen saturation level above 92%. LVN 1 further stated the importance of following physician's order was to prevent Resident 22 in the development of codependence on oxygen use. On 5/3/23 at 1647 hours, an interview was conducted with the DON. The DON was informed and verified the above findings and stated the licensed nurses were expected to follow the physician's orders as prescribed. 2. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed to change the oxygen cannula and tubing every seven days or as needed. a. On 5/2/23 at 0815 hours during an initial tour, Resident 22 was observed sitting up in her wheelchair with the oxygen nasal cannula in her nose. Resident 22's oxygen tubing was observed attached to an oxygen machine. Resident 22's oxygen tubing was observed not dated. Medical record review for Resident 22 was initiated on 5/2/23. Resident 22 was readmitted to the facility on [DATE], with diagnosis of COPD. Review of Resident 22's Order Summary Report dated May 2023, showed a physician's order dated 12/5/22, for an oxygen inhalation at 2 liters per minute via nasal cannula PRN for SOB and to keep the oxygen saturation level greater than 92%. Review of Resident 22's care plan titled Receiving Oxygen Therapy dated 12/5/22, showed an intervention to change the oxygen tubing per the facility's protocol. On 5/2/23 at 0824 hours, an observation and concurrent interview was conducted with the DSD/IP. The DSD/IP verified the above findings and stated it was important to change the oxygen tubing to prevent infection. On 5/5/23 at 1342 hours, an interview was conducted with the DON. The DON stated the oxygen tubings were expected to be changed weekly to prevent infection. b. On 5/2/23 at 0829 hours, during an initial tour, Resident 9 was observed lying in bed with the head of the bed elevated and the oxygen nasal cannula in her nose. The oxygen tubing was observed attached to an oxygen machine. Resident 9's oxygen tubing was observed not dated. Medical record review for Resident 9 was initiated on 5/2/23. Resident 9 was admitted on [DATE]. Review of Resident 9's Order Summary Report dated May 2023, showed a physician's order dated 3/22/23, for an oxygen at 2 liters per minute via nasal cannula, may titrate up to 5 liters per minute PRN for SOB. Review of Resident 9's care plan titled Receiving Oxygen Therapy dated 3/24/23, showed an intervention to change the oxygen tubing per the facility's protocol. On 5/2/23 at 0838 hours, an observation and concurrent interview was conducted with the DSD/IP. The DSD/IP verified the above findings and stated it was important to change the oxygen tubing to prevent infection. On 5/5/23 at 1342 hours, an interview was conducted with the DON. The DON stated the oxygen tubings were expected to be changed weekly to prevent infection.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to attain and maintain the highest physical well-being for one of 14 final sampled residents (Resident 529). * The facility failed to ensure a diet change order recommendation for Resident 529's fluid restriction (a diet which limits the amount of daily fluid consumption) from the dialysis center was followed and carried out in a timely manner. This had the potential for Resident 529 having excess fluids which may affect other vital organs in the body due to impaired kidney functions. Findings: Review of the facility's P&P titled Encouraging and Restricting Fluids revised 10/2010 showed when a resident has been placed on a restricted fluid, remove the water pitcher from the room. On 5/2/23 at 1034 hours, during an initial tour, Resident 529 was observed sitting up in her bed. There was a green water pitcher and two plastic cups half filled with water observed on Resident 529's bed side table. Resident 529 stated she was on a fluid restriction and could only drink a little. Medical record review for Resident 529 was initiated on 5/2/23. Resident 529 was readmitted to the facility on [DATE], with the diagnosis of End Stage Renal Disease required hemodialysis. Review of Resident 529's H&P examination dated 4/9/23, showed Resident 529 had the capacity to understand and make decisions. Review of Resident 529's Order Summary Report dated April and May 2023 showed a physician's order dated 4/4/23, for Resident 529 to go to dialysis on Mondays, Wednesdays, and Fridays, with a chair time of 1400 hours. Review of Resident 529's facility's document titled SNF: Pre and Post Dialysis assessment dated [DATE], showed the completed assessment form from the dialysis unit with a recommendation of a diet change to fluid restriction of 1200 ml. Review of Resident 529's facility document titled SNF: Pre and Post Dialysis assessment dated [DATE], showed a post it note attached to the document showing Does patient have any fluid restriction? We don't have any order for fluid restriction for her, but we recommend it to her. Review of Resident 529's Progress Notes for April 2023 did not show documentation of a follow up with the dialysis unit recommendation of diet change for fluid restriction of 1200 ml. Review of Resident 529's Order Summary Report dated April 2023 did not show an order for Resident 529's fluid restriction of 1200 ml recommended by the dialysis center. Review of Resident 529's Medication Administration Record dated April 2023 did not show an order for Resident 529's fluid restriction of 1200 ml recommended by the dialysis center. Review of Resident 529's Nutrition Evaluation dated 4/4/23, showed Resident 529's diet of regular, consistent carbohydrate (CCHO), no added salt (NAS), renal, and no fluid restriction. Review of Resident 529's Order Summary Report dated May 2023, showed a physician's order dated 5/3/23, to have 1200 ml/ 24-hour fluid restriction with the breakdown as follows: * Dietary: - Breakfast = 240 ml - Lunch = 240 ml - Dinner = 240 ml * Nursing: - 7 am - 3 pm shift = 180 ml - 3 pm - 11 pm shift = 180 ml - 11 pm - 7 am shift = 120 ml Review of Resident 529's care problem titled Renal Disease dated 5/3/23, showed an intervention for 1200 ml/ 24-hour fluid restriction. On 5/5/23 at 1004 hours, Resident 529 was observed sleeping on her bed in her room. There was a green water pitcher filled with water observed on her bed side table. On 5/5/23 at 0958 hours, an interview was conducted with LVN 2. LVN 2 stated Resident 529 was on fluid restriction and a water pitcher should not be on Resident 529's bedside table to control Resident 529's fluid intake and to prevent fluid overload. On 5/5/23 at 1005 hours, an observation, medical record review, and concurrent facility document review was conducted with LVN 2. LVN 2 verified the above findings and stated the recommendation for fluid restriction of 1200 ml from the dialysis center on 4/5/23, should have been followed up right away. On 5/5/23 at 1043 hours, an interview, medical record review, and concurrent facility document review was conducted with the DON. The DON was informed and verified the above findings. The DON stated the resident on dialysis should not have a water pitcher at the bed side. The DON did not find documentation of the licensed nurses carrying out the recommendation written in the SNF: Pre/Post Dialysis Assessment on 4/5/23 or 4/17/23, for the 1200 ml fluid restriction. On 5/5/23 at 1118 hours, an interview was conducted with the RDN. The RDN stated she did not receive a diet slip (a communication sheet used by the nurses and the RDN with resident's diet order change) from the nurses and was not aware of the dialysis center recommendation for a diet change of fluid restriction of 1200 ml on 4/5/23 or 4/17/23.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services for two of 14 final sampled residents (Residents 1 and 729) and one nonsampled resident (Resident 3) to meet the needs of each resident. The facility failed to ensure administration of the narcotic pain medications for Residents 1, 3, and 729 were accurately documented to ensure accurate reconciliation and prevent medication administration errors. These failures posed the risk for diversion of controlled medications and medication administration errors. Findings: Review of the facility's P&P titled Controlled Substances revised 4/2019 showed upon administration of controlled medication, the nurse administering the medication is responsible for recording: - Name of the resident receiving the medication; - Name, strength, and dose of the medication; - Time of administration; - Method of administration; - Quantity of the medication remaining; and - Signature of nurse administering medication. Review of the facility's P&P titled Administering Medication revised 4/2019 showed the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones. 1. Medical record review for Resident 729 was initiated on 5/2/23. Resident 729 was admitted to the facility on [DATE]. Review of Resident 729's H&P examination dated 4/11/23 showed Resident 729 had the capacity to understand and make decisions. Review of Resident 729's Order Summary Report dated May 2023 showed a physician's order dated 4/11/23, to administer tramadol (opioid pain medication) 50 mg tablet by mouth every six hours as needed for pain. On 5/4/23 at 1537 hours, an interview, record review, and concurrent inspection of Medication Cart A was conducted with the CQA/IP. Review of Resident 729's Individual Resident's Controlled Drug Record for the administration of tramadol 50 mg showed one tablet of tramadol 50 mg was signed out by LVN 3 on 5/3/23 at 2200 hours. The number of tablets in the bubble pack (a package used to dispense medications) matched the number of tramadol 50 mg tablets in the Individual Resident's Controlled Drug Record. However, review of Resident 729's electronic MAR dated May 2023 did not show tramadol 50 mg was administered to Resident 729 on 5/3/23 at 2200 hours. The CQA/IP verified the findings. Further review of Resident 729's Individual Resident's Controlled Drug Record for the administration of tramadol 50 mg showed one tablet of tramadol 50 mg was signed out by LVN 7 on 4/16/23 at 2030 hours. However, review of Resident 729's electronic MAR for April 2023 did not show tramadol 50 mg was administered to Resident 729 on 4/16/23 at 2030 hours. On 5/4/23 at 1356 hours, an interview was conducted with Resident 729. Resident 729 stated tramadol 50 mg was one of her pain medications. Resident 729 stated she did not receive her tramadol 50 mg on 5/3/23 at 2200 hours. 2. Medical record review for Resident 3 was initiated on 5/2/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 5/2/22, showed Resident 3 could make needs known but could not make medical decisions. Review of Resident 3's Order Summary Report dated May 2023 showed a physician's order dated 1/22/23, to administer Norco (narcotic pain medication) for 5-325 mg tablet by mouth every four hours as needed for severe pain. On 5/5/23 at 0850 hours, an interview, record review, and concurrent inspection of Medication Cart A was conducted with LVN 2. Review of Resident 3's Individual Resident's Controlled Drug Record for the administration of hydrocodone-acetaminophen (generic name for Norco) 5-325 mg showed one tablet of hydrocodone-acetaminophen 5-325 mg was signed out by LVN 8 on 4/20/23 at 1700 hours. However, review of Resident 3's electronic MAR for April 2023 did not show hydrocodone-acetaminophen 5-325 mg was administered to Resident 3 on 4/20/23 at 1700 hours. LVN 2 verified the findings. On 5/5/23 at 1022 hours, an interview was conducted with the DON. The DON verified the process for administering the controlled medications was to document the removal of the controlled medication on the narcotic count sheet and document the medication administration on the electronic MAR after administering the medication to the resident. The DON verified the above findings. 3. Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was originally admitted to the facility on [DATE], and recently readmitted on [DATE]. Review of Resident 1's physician orders showed an order dated 4/16/21, for tramadol HCL 50 mg ½ tablet (25 mg) by mouth every six hours as needed for moderate to severe pain. Review of Resident 1's Individual Resident's Controlled Drug Record for tramadol HCL 50 mg tablet showed Tramadol 50 mg was signed out by the nurse on 3/7/23 at 0720 hours, 3/30/23 at 2100 hours, and 4/30/23 at 0500 hours. Review of Resident 1's MAR for March and April 2023 showed Tramadol was documented as administered on 3/5/23 only. There was no documented evidence tramadol was administered to the resident on 3/7, 3/30, and 4/30/23, when the medications were signed out. Review of Resident 1's progress notes for March and April showed no notes documented for 3/7 and 3/30/23. Review of Resident 1's progress note dated 4/30/23 at 0508 hours, showed LVN 7 stated Resident 1 had no complaints of pain. On 5/5/23 at 1022 hours, and interview was conducted with the DON. When asked what the facility process was on administering the narcotic medications, the DON stated the nurses must sign out the narcotic medication on the narcotic count sheet and must document in the MAR to show the medication was administered to the resident. When asked what the process was if a resident refused a narcotic medication, the DON stated two nurses must dispose of the narcotic and sign on the narcotic count sheet to show the medication was wasted. On 5/5/23 at 1530 hours, the Administrator, DON, CQA/IP Nurse were informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 1) was free from a significant medication error when Resident 1 had duplicate metoprolol orders. This failure had the potential to cause harm to Resident 1. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications should be administered in accordance with prescriber orders, including any required time frames. Medical record review for Resident 1 was initiated on 5/2/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident had the diagnosis of hypertension and history of falls. Review of Resident 1's physician orders showed two active orders for the metoprolol medication as follows: - metoprolol tartrate 50 mg one tablet by mouth twice a day, started on 4/13/23, and discontinued on 5/3/23. - metoprolol tartrate 50 mg one tablet by mouth twice a day, started on 4/21/23, and discontinued on 5/2/23. Review of Resident 1's MAR for April and May 2023 showed Resident 1 received metoprolol tartrate 50 mg on the following dates and times: - at 0700 hours from 4/14 to 5/3/23 - at 0900 hours from 4/11 to 4/17, 4/20 to 4/23, and 4/25 to 5/2/23 - at 1700 hours from 4/1 to 4/18, 4/20 to 4/27, and 4/29 to 5/2/23 Review of the Medication Regimen Review Report for April 2023 showed there was no recommendation from the Pharmacy Consultant regarding the use of metoprolol medication for Resident 1. On 5/3/23 at 1153 hours, an interview and concurrent medical record review was conducted with the CQA/IP who filled in as the medication cart nurse for the facility on 5/3/23. The CQA/IP stated Resident 1 had two active metoprolol orders and verified Resident 1's MAR showed the resident had received metoprolol 50 mg three times a day during April and May 2023. When asked how many doses of metoprolol Resident 1 should have received, the CQA/IP stated Resident 1 should have only received the metoprolol two times a day. The CQA/IP further stated she was unsure why there was a duplicate metoprolol order. On 5/5/23 at 1148 hours, an interview was conducted with the facility's Pharmacy Consultant . When asked about her Monthly Medication Reviews (MMR) with the facility, the pharmacy consultant stated she reviewed all residents' medication orders and MARs. The Pharmacy Consultant stated she completed the facility's most recent MMR on 4/26/23. When asked about Resident 1's duplicate metoprolol orders, the Pharmacy Consultant stated she either missed the duplicate order for the metoprolol or changes to the metoprolol orders were completed after her review. When asked what the risks were for a resident who received more than the ordered dose of metoprolol, the pharmacy consultant stated there was a risk of lowering the resident's heart rate and blood pressure. She further stated a resident who was overdosed on metoprolol should be monitored more frequently. On 5/5/23 at 1530 hours, the Administrator, DON, CQA/IP were informed and acknowledged the above findings. Cross reference to F684.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in a safe and secure manner when Medication Cart A was left unlocked and unattended. This failure posed the risk for non-licensed staff and visitor to have access to the medications. Findings: Review of the facility's P&P titled Storage of Medications revised 4/2019 showed the facility stores all drugs and biologicals in a safe manner, secure, and orderly manner. Unlocked medication carts are not left unattended. On 5/3/23 at 1513 hours, Medication Cart A by the Nurse's Station A was observed unlocked and unattended. Family member from Room A and staff were observed passing by the unlocked Medication Cart A. On 5/3/23 at 1519 hours, LVN 1 was observed passing by and locked the Medication Cart A. LVN 1 acknowledged Medication Cart A was left unlocked and unattended. When asked if Medication Cart A was supposed to be left unlocked and unattended, LVN 1 stated no. On 5/3/23 at 1520 hours, LVN 3 was made aware Medication Cart A was left unlocked and unattended. An inspection of Medication Cart A was conducted with LVN 3. Medication Cart A contained the over-the-counter medications, eye drops, breathing treatments and medication bubbles packs. LVN 3 acknowledged the medication carts should not be left unlocked when unattended. On 5/5/23 at 1215 hours, an interview with the DON was conducted. When asked regarding the unlocked and unattended Medication Cart A, the DON stated the medication carts should be locked when unattended to prevent the staff, residents, or visitor to have access to the medications.

CONCERN (D)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected 1 resident

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Based on observation, interview, facility document review, and the facility P&P review, the facility failed to ensure one of four cooks (Cook 1) had the appropriate skill set to safely perform the daily operations of the Food and Nutrition Services Department when: * [NAME] 1 was unable to correctly calibrate a food thermometer. * [NAME] 1 failed to wash hands properly. * [NAME] 1 failed to follow the recipe for puree vegetable. These failures had the potential for unsafe food practices which could lead to foodborne illnesses in a highly susceptible population the residents who received food prepared in the kitchen. Findings: Review of the facility's document titled [NAME] Job Description - Principal Responsibilities, under the section Technical: - prepares nutritious and attractive meals and supplements for all residents in a manner. - prepare meals and supplements according to Federal, State, and Corporate requirements. - performs duties in a safe and sanitary manner. Review of the facility's document titled Standard of Performance signed by [NAME] 1 on 5/12/18, under the section Technical showed: - prepares food according to the standardized recipes. - serves food according to proper portion control, therapeutic requirements, and temperature. - prepares food under safe and sanitary conditions. Review of the facility's document titled Technical Skills Self-Assessment and Orientation Checklist for [NAME] signed by [NAME] 1 on 5/12/18, showed an orientation topic including menu, hand washing procedure, and equipment. On 5/3/23 at 1043 hours, an interview with the DSD/IP was conducted. When asked if she kept the file of employee competency evaluations, the DSD/IP stated the employee files were with the BOM. On 5/3/23 at 1051 hours, an interview with the BOM was conducted. When asked if there were more employee records for [NAME] 1, the BOM stated the facility only had one file folder for employees. On 5/4/23 at 1054 hours, an interview with the CDM was conducted. The CDM verified she conducted an annual competency for the kitchen staff; however, review of [NAME] 1's employee file did not show an annual competency evaluation done after 2018. 1. According to the FDA Food Code 2022, Section 4-502.11, food temperature measuring devices shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. Review of the facility's P&P titled Food Preparation and Services revised 4/2019 showed food thermometers used to check food temperatures are clean, sanitized, and calibrated. According to ServSafe (company that provide safety training and certification for foodservice professionals) material titled How to Calibrate a Thermometer, showed thermometers should be calibrated regularly to make sure the readings are correct. The ice-point method is the most widely used method to calibrate a thermometer. According to CDN (company that sells measurement tools) material titled Cooking Thermometer dated 5/2020, under the section for How to Calibrate Your Thermometer, section for Making an Ice Slurry, showed to fill a cup measuring container with a slurry of ice water using three parts crushed ice to one part water and allow to stand for 3-5 minutes. In the section for Using the Calibration Tool on Sheath showed to immerse the stem into the middle of the ice slurry or boiling water (212 degrees Fahrenheit/100 degrees Celsius at sea level) to a depth of at least three inches. Do not let the stem touch the bottom of the container. Review of the facility's In-service Record to dietary staff conducted on 5/12/22, showed a topic on calibrating thermometers attended by [NAME] 1. On 5/3/23 at 1005 hours, a concurrent observation on food thermometer calibration and interview with [NAME] 1 was conducted. [NAME] 1 was observed filling a small cup with ice water halfway full, then inserted the CDN IRT220 food thermometer allowing the thermometer to touch the bottom and side of the cup. When asked if the thermometer should touch the bottom or side of the cup, [NAME] 1 stated she was not aware that the thermometer should not touch the bottom or side of the cup. [NAME] 1 acknowledged receiving an in-service on the food thermometer calibration; however, [NAME] 1 failed to perform the correct food thermometer calibration. 2. Review of the facility's P&P titled Food Preparation and Service revised 4/2019 showed food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illnesses. On 5/2/23 at 0902 hours, an observation in the kitchen was conducted. [NAME] 1 was observed on the dirty side of dish machine loading dirty dishes onto the dish rack, then proceeded to take the clean trays without washing her hands. On 5/3/23 at 0914 hours, an observation in the kitchen was conducted. [NAME] 1 was observed at the handwashing sink. [NAME] 1 was observed washing her hands with soap for only three seconds. On 5/5/23 at 1100 hours, an interview with [NAME] 1 was conducted. When asked regarding handwashing, [NAME] 1 did not know how long she was supposed to wash her hands. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN expected the kitchen staff to perform proper hand washing. Review of the facility's In-service Records for the dietary staff showed a topic on handwashing conducted on 4/13/23, and a topic on personal hygiene conducted on 7/14/22. The facility's In-service Records showed [NAME] 1 attended the in-services; however, [NAME] 1 failed to perform the proper hand hygiene. Cross reference to F812, example #1. 3. On 5/2/23 at 1091 hours, during the concurrent observation of puree meal preparation and interview with [NAME] 1, [NAME] 1 stated pureed food should be mashed potato consistency. [NAME] 1 was observed not following the recipe for pureed vegetables that resulted in nectar thick consistency vegetables. On 5/3/23 at 1013 hours, during an interview with the Certified Dietary Manager, the Certified Dietary Manager verified the pureed green beans served during lunch on 5/2/23, was not a correct consistency and acknowledged [NAME] 1 did not follow the recipe for pureed vegetable. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN expected the kitchen staff should follow recipe when preparing food for the residents. Cross reference to F803.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility document review, the facility failed to ensure the puree menu was followed for six of six residents on a puree diet. * The facility failed to follow the recipe for pureed vegetables. This failure had the potential to not meet the resident's nutritional needs. Findings: Review of the facility's document titled, Recipe: Pureed Vegetables showed for six serving recipe of vegetables, to add one to three ounces of warm fluid such as milk, or low sodium broth. Suggested amounts vary from vegetable to vegetable and some vegetables may not require any liquid at all. Under the Recipe Directions, measure out the total number of portions needed for puree diet, then puree on low speed to a paste consistency before adding any liquids, gradually add warm liquid if needed, puree on low speed, and adding stabilizer where needed. Puree should reach a consistency of applesauce. On 5/2/23 at 1019 hours, an observation of the puree meal preparation was conducted. [NAME] 1 stated pureed food should be mashed potato consistency. [NAME] 1 was observed scooping six servings of green beans using #12 scoop (1/3 cup) then added three scoops (3 ounces) of broth into the blender. [NAME] 1 pureed the green beans in the blender, then added two half teaspoons of thickener powder. [NAME] 1 verified the pureed green beans was not a correct consistency but stated it would be thicken when placed in the oven. On 5/2/23 at 1116 hours, an observation of the tray line was conducted. The pureed green beans was observed nectar thick in consistency when plated. On 5/3/23 at 1013 hours, an interview with the Certified Dietary Manager was conducted. The Certified Dietary Manager verified the pureed green beans served during lunch on 5/2/23, was not a correct consistency and acknowledged [NAME] 1 did not follow the recipe for pureed vegetables. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN expected the kitchen staff should follow the recipe when preparing food for the residents.

CONCERN (D)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

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5. On 5/2/23 at 0833 hours, an observation and concurrent interview was conducted with Resident 25. Resident 25 was observed to have the following food items at the bedside: - an undated, opened black plastic container with sliced oranges; - an undated, opened black plastic container with pineapple chunks and grapes; - an undated clear plastic bag of cookies; - an unopened package of uncured ham and cheese lunch kit observed with a keep refrigerated label. Resident 25 stated her friend brought the food to the facility the day before. On 5/3/23 at 0755 hours, an observation and concurrent interview was conducted with Resident 25. Resident was observed to have the following food items at the bedside: - an undated, opened black plastic container with pineapple chunks and grapes; - an unopened package of uncured ham and cheese lunch kit observed with a keep refrigerated label; -an undated, unopened chocolate and vanilla pudding; and -a bowl of yogurt dated 5/2/23. Resident 25 stated she ate half of the pineapple chunks and all the sliced oranges during breakfast. Resident 25 stated the facility staff gave her the pudding and bowl of yogurt the night before. On 5/3/23 at 0816 hours, an interview was conducted with the DSD/IP. The DSD/IP verified Resident 25 had unlabeled and undated food items at the bedside. The DSD/IP stated the yogurt, pudding, cut-up fruits and packaged uncured ham and cheese lunch kit were perishable food and required refrigeration. On 5/4/23 at 1103 hours, a follow-up interview was conducted with the DSD/IP. The DSD/IP stated she had not provided the staff any training of safe food handling practices. On 5/4/23 at 1425 hours, an interview was conducted with the DON. The DON stated perishable food items from home, including sliced oranges, pineapple chunks, and packaged uncured ham and cheese lunch kit, should be refrigerated, labeled, and dated to prevent food borne illnesses. Based on observation, interview, and facility P&P review, the facility failed to implement their P&P to ensure food items brought to the resident from outside were handled to ensure safe storage, preparation, and consumption for one of the 14 final sampled residents (Resident 26) and one of nonsampled resident (Resident 25). * The facility failed to ensure Resident 26's food items from outside were properly stored. * The facility failed to discard Resident 25's expired mango drink in the resident's refrigerator. * The facility failed to provide the family/visitors a copy of the facility's P&P for Food Brought by Family/Visitors. * The facility failed to provide in-service to the facility staff on safe food handling. * The facility failed to store Resident 25's perishable food items brought from outside were properly stored. These failures posed the risk of resident food brought to the facility from outside not being handled in a safe manner which posed the risk of food borne illnesses. Findings: Review of the facility's P&P titled Food Brought by Family/Visitors revised 10/2017 showed the following: - Nursing staff will provide family/visitors who wish to bring foods to the facility with a copy of this policy. Residents will also be provided a copy in a language and format he or she can understand. - All personnel involved in preparing, handling, serving, or assisting the resident with meals or snacks will be trained in safe food handling practices. - Food brought by family/visitors that is left with the resident to consume later will be labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers will be labeled with the resident's name, the item and the use by date. - Potentially hazardous food that are left out for resident without a source of heat or refrigeration longer than two hours will be discarded. 1. On 5/2/23 at 1143 hours, an observation of the resident's refrigerator located in the dining room was conducted. An undated food in a sealed plastic container and undated food item wrapped in foil labeled with Resident 26' name were observed in the resident's refrigerator. On 5/2/23 at 1158 hours, a concurrent observation and interview was conducted with the DSD/IP. The DSD/IP verified Resident 26's food items were undated and should have been dated. 2. Review of the facility's P&P titled Food Brought by Family/Visitors revised 10/2017 showed the nursing staff will discard perishable foods on or before the use by date. On 5/2/23 at 1143 hours, an observation of the resident's refrigerator inside the dining room was conducted. Resident 25's open bottle of mango drink with an expiration date of 4/12/23, was observed inside the resident's refrigerator. On 5/2/23 at 1158 hours, a concurrent observation and interview was conducted with the DSD/IP. The DSD/IP acknowledged Resident 25's mango drink had expired on 4/12/23, and should have been discarded on or before the expiration date. 3. On 5/3/23 at 0950 hours, an interview with the DON was conducted. When asked if the nursing staff provided a copy of the facility's Food Brought by Family/Visitors P&P to the resident's responsible party, the DON stated the facility's P&P was included in the facility's admission packet. On 5/3/23 at 1028 hours, an interview with the Business Office Manager was conducted. When asked if the facility's P&P for Food Brought by Family/Visitors was included in the admission packet, the Business Office Manager verified it was not included in the admission packet. 4. On 5/3/23 at 0830 hours, an interview with the DSD/IP was conducted. When asked if the facility provided in-service to the staff on safe food handling, the DSD/IP stated there was no documentation of the staff in-service on safe food handling. On 5/3/23 at 0950 hours, an interview with the DON was conducted. The DON verified there was no documentation of the staff in-service on safe food handling.

CONCERN (D)

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

Deficiency F0836 (Tag F0836)

Could have caused harm · This affected 1 resident

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Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the nutritional assessments were performed by a qualified RD for one of 14 final sampled residents (Resident 1) when the Dietary Manager who did not meet the qualifications and skill set performed the assessment of the facility's residents' nutritional status. This failure posed the risk for residents' nutritional needs to not be met. Findings: The online dictionary defines review as a formal assessment or examination of something with the possibility of intention of instituting change if necessary this definition, therefore, implies a review as an assessment, a role designated for the RD. Based on state regulations (California business and professions code 2586), the RD is the professional permitted to conduct medical nutrition therapy which includes assessment, determination of nutrition diagnosis and recommendation and implementation of nutrition care and intervention. Review of the facility's P&P titled Nutrition Assessment revised 10/2017 showed in part, 1. The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. Review of the facility document titled Director, Nutritional Services Job Description signed and dated by the Certified Dietary Manager on 9/12/16, showed the following: - Principle Responsibilities: Clinical: ensures the timely preparation and delivery of nutritious and attractive meals and supplements to all residents according to physician order and in compliance with Federal, State and company requirements. Maintains a safe and sanitary working environment. Ensures that meals are served according to expressed resident preferences. Plan, implements and revises menus to meet resident needs. Interacts effectively with other resident services according to total care plan approach. Review of the electronic medical record for Resident 1 and concurrent phone interview was conducted with the RDN on 5/04/23 at 1321 hours. The RDN confirmed the Certified Dietary Manager completed the quarterly nutrition evaluations for all residents. The quarterly nutrition evaluation for Resident 1 dated 12/1/22, was reviewed with the RDN. The RDN confirmed the quarterly nutrition evaluation showed Resident 1's weight of 139 lbs was from 11/1/22. The RDN confirmed the quarterly nutrition evaluation showed Resident 1 had not lost weight, was not at weight loss risk, was not at dehydration risk, did not have any nutrition interventions/recommendations, and showed to continue to monitor monthly weights and po intake. The RDN agreed the 12/2/22 weight of 136 lbs should have been included in the December quarterly nutrition evaluation and the insidious weight loss of seven lbs (6%) from 9/1/2022 to 12/2/2022, should have been addressed in the quarterly nutrition evaluation. The RDN further agreed that Resident 1 was at risk for weight loss and dehydration due to poor po intake. The RDN confirmed the nutrition evaluation form did not include resident's po intake. The RDN was asked if she reviewed the quarterly nutrition evaluations that were completed by the Certified Dietary Manager. The RDN confirmed she did not review the quarterly nutrition evaluations completed by the Certified Dietary Manager. The RDN further stated she was not aware the Certified Dietary Manager was not a qualified individual to perform nutrition evaluations. On 5/5/23 at 1331 hours, an interview was conducted with the Administrator. The Administrator was not aware a Certified Dietary Manager was not qualified to complete resident assessments. The Administrator was not aware of the California business and professions code 2586 that the RD was the professional permitted to conduct medical nutrition therapy which included assessment, determination of nutrition diagnosis, and recommendation and implementation of nutrition care and intervention. The Administrator agreed the RD should be cosigning or completing the quarterly nutrition evaluations. Cross reference to G692, example #2.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Administering Medications through a Small Volume (Handheld) Nebulizer revised October 2010 showed to rinse and disinfect the nebulizer equipment according to facility protocol and when the equipment is completely dry, store in a plastic bag with the resident's name and the date on it. On 5/3/23 at 0746 hours, an observation and concurrent interview was conducted with Resident 729. Resident 729's nebulizer mask was observed on top of magazines on her bedside table. Resident 729 stated she last used the nebulizer mask around one hour ago. On 5/3/23 at 0800 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 729's nebulizer mask was on the resident's bedside table and on top of her magazines. LVN 1 was observed placing the nebulizer mask inside a labeled plastic bag, which was hanging on Resident 729's oxygen concentrator. LVN 1 stated Resident 729's nebulizer mask should be stored inside the plastic bag to keep the nebulizer mask clean. On 5/4/23 at 1012 hours, an interview was conducted with the DSD/IP. When asked about the proper storage of the nebulizer mask after use, the DSD/IP stated the nebulizer mask should be rinsed with water and dried with a paper towel, then stored inside a labeled plastic bag to keep the equipment sanitary. The DSD/IP stated she had not provided the licensed nurses in-services regarding the proper storage of the nebulizer equipment. 5. Review of the facility's P&P Catheter Care Urinary revised September 2014 showed under Infection Control: urinary catheter tubing and drainage bags should be kept off the floor. Medical record review for Resident 5 was initiated on 5/2/23. Resident 5 was admitted to the facility on [DATE], with diagnoses including UTI and sepsis. On 5/2/23 at 0834 hours, during an initial tour of the facility, Resident 5's indwelling urinary catheter tubing and bag were observed on the floor. On 5/2/23 at 0910 hours, and 5/3/23 at 0803 hours, during the observations, Resident 5's indwelling urinary catheter tubing was observed on the floor. On 5/3/23 at 0815 hours, a concurrent interview and observation was conducted with CNA 2. Upon observing Resident 5's urine catheter system, CNA 2 verified Resident 5's indwelling urinary catheter tubing was on the floor. CNA 2 further stated no part of the urine catheter system should be on the floor. On 5/4/23 at 0907 hours, an interview was conducted with the DSD/IP. When asked, the DSD/IP stated indwelling urinary catheter tubings and bags should not be on the floor. On 5/5/23 at 1530 hours, the Administrator, DON, CQA/IP Nurse were informed and acknowledged the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection practices to help prevent the development and transmission of diseases and infection for three of 14 final sampled residents (Residents 5, 529, and 729). * The facility failed to ensure the licensed nurse performed hand hygiene during wound care treatment for Resident 529. * The facility failed to store Resident 729's nebulizer equipment in a sanitary condition. * The facility failed to ensure the urinary catheter tubing and bag were kept off the floor for Resident 5. These failures have the potential risk for transmission of disease-causing microorganisms and infections to the residents. Findings: 1. Review of the facility's P&P titled Handwashing/ Hand Hygiene revised 8/2019 showed all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The use of gloves does not replace handwashing/hand hygiene. Use of an alcohol-based hand rub containing at least 62% alcohol, or, alternatively, soap (antimicrobial or non-microbial) and water for the following situations: - before and after direct contact with residents; - before handling clean or soiled dressings, gauze pads, etc.; - before moving from a contaminated body site to a clean body site during resident care; - after handling used dressings, contaminated equipment, etc.; - after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; - after removing gloves Medical record review for Resident 529 was initiated on 5/3/23. Resident 529 was readmitted to the facility on [DATE]. Review of Resident 529's Order Summary Report dated April 2023, showed a physician's treatment order dated 5/3/23, for the right and left great toes surgical site to cleanse with normal saline, pat dry, paint with betadine, cover with a gauze and ABD (an abdominal wound dressing), and wrap with kerlix and ACE bandage (elastic bandage wrap) every other day for 21 days. On 5/3/23 at 1054 hours, a wound care observation for Resident 529 was conducted with LVN 1. LVN 1 was observed placing a white disposable drape underneath Resident 529's bilateral feet with gloves on. LVN 1 proceeded to remove the old ACE bandage from the right foot, and then removed the ACE bandage from the left foot, then threw the ACE bandages to the trash can. LVN 1 doffed her gloves and donned new gloves without performing handwashing or hand hygiene. LVN 1 placed another white disposable drape underneath Resident 529's bilateral feet one at a time. LVN 1 continued to cut the wrapped gauze bandage with a scissors on the right foot, then the left foot. After removing Resident 529's old and soiled dressing, LVN 1 patted the right foot surgical toe wound with a gauze to dry, painted the wound with betadine twice, opened a new rolled gauze from its container, removed the gloves, and put on the new gloves without performing handwashing or hand hygiene. LVN 1 proceeded to providing treatment to the left great toe surgical wound. After the left great toe surgical wound was painted with iodine swabs and covered with a gauze, LVN 1 removed the gloves and put on the new gloves without performing handwashing or hand hygiene. On 5/3/23 at 1132 hours, LVN 1 was informed of the observations during wound care treatment for Resident 529. LVN 1 acknowledged the above findings and further stated she was not aware she missed performing handwashing or hand hygiene in between changing from the old gloves to new gloves. LVN 1 stated it was important to perform hand hygiene for infection control purposes. On 5/3/23 at 1624 hours, an interview was conducted with the DSD/IP. The DSD/IP stated the staff were supposed to perform the hand hygiene during the dressing change and in between changing gloves to prevent cross contamination or spread of bacteria.

CONCERN (E)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Medical record review for Resident 5 was initiated on 5/2/23. Resident 5 was admitted to the facility on [DATE]. On 5/2/23 at 0834 hours, during an initial tour of the facility, Resident 5 was observed asleep in bed with upper bilateral side rails elevated. On 5/3/23 at 1136 hours, during an observation, Resident 5 was observed in bed with bilateral upper side rails elevated. Review of Resident 5's H&P examination dated 12/24/22, showed Resident 5 did not have the capacity to understand or make decisions. Review of Resident 5's MD'S dated 12/21/22, showed Resident 5 required total dependence on staff for bed mobility and required assistance from more than two staff. Review of Resident 5's Physician Orders showed an order dated 1/27/23, for bilateral upper siderails while in bed for mobility and repositioning. Review of Resident 5's Restraint Assessment undated, did not show an indication for the use of side rails. Review of Resident 5's medical record did not show an informed consent was obtained for the use of side rails. On 5/4/23 at 1032 hours, an interview was conducted with the DON. When asked about the Restraint Assessment form, the DON stated the Restraint Assessment form was not for a bed rails assessment. When asked if they provided side rail information and consent to the residents, she stated the facility did not have a side rails consent in place. On 5/4/23 at 1108 hours, an interview was conducted with the Maintenance Supervisor. When asked if he had documents regarding the bed rails from the manufacturer, he stated any paperwork regarding the bed rails was kept with the previous DSD who no longer worked at the facility. On 5/4/23 at 1124 hours an interview was conducted with the DSD. When asked if she had any paperwork regarding the facility's bed rails, she stated she did not handle the bed rails in the facility. 7. Medical record review for Resident 21 was initiated on 5/2/23. Resident 21 was admitted to the facility on [DATE], with a diagnosis of dementia. On 5/2/23 at 0815 hours, and on 5/3/23 at 0800 hours, during an initial tour of the facility, Resident 21 was observed with the bilateral upper side rails elevated. Review of Resident 21's H&P examination dated 12/01/22, showed Resident 21 did not have the capacity to understand or make decisions. Review of Resident 21's MDS dated [DATE], showed Resident 5 required extensive assistance from staff for bed mobility. Review of Resident 21's Physician Orders showed an order dated 11/21/23, for bilateral upper side rails while in bed for mobility and repositioning. Review of Resident 21's Restraint Assessment undated, did not show the indication the use of side rails. Review of Resident 21's medical record did not show an informed consent was obtained for the use of side rails. On 5/4/23 at 1032 hours, an interview was conducted with the DON. When asked about the Restraint Assessment form, the DON stated the Restraint Assessment form was not use for a bed rails assessment. When asked if they provided side rail information and asked for a consent from the residents/responsible parties, she stated they did not have a side rails informed consent in place. On 5/4/23 at 1108 hours, an interview was conducted with the Maintenance Supervisor. When asked if he had documents regarding the bed rail manufacturer, he stated any paperwork regarding bed rails was kept with the previous DSD who no longer worked at the facility. On 5/4/23 at 1124 hours, an interview was conducted with the DSD. When asked if she had any paperwork regarding the facility's bed rails, she stated she did not handle the bed rails in the facility. Cross reference to F909 Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the entrapment assessments, alternative to side rails, and/or obtained informed consents were completed for the use of side rails for seven of 14 final sampled residents (Residents 5, 8, 9, 21, 24, 26, and 529). These failures had the potential to put the residents at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed Side Rails. Residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and ed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. Review of the facility's P&P titled Use of Restraints revised 4/2017 showed restraint shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e., side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Prior to placing a resident in restraint, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. Restraints shall only be used upon the written order of a physician and after determining consent from the resident and/or representative (sponsor). Resident and/or surrogate shall be informed about the potential risks and benefits for all options under consideration, including the use of restraint, not using restraint, and the alternatives to restraint use. Restraint individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination. 1. On 5/2/23 at 0838 hours, and 5/3/23 at 0756 hours, Resident 9 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 9 was initiated on 5/2/23. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's MDS dated [DATE], showed Resident 9 was moderate impared cognitively and required extensive assistance of two staff for bed mobility. Review of Resident 9's Order Summary Report dated May 2023 did not show the physician's order for Resident 9's bilateral half side rails use. Review of Resident 9's Restraint Assessment undated, did not show the indication for the use of Resident 9's bilateral half bed side rails, the use of least restrictive measures, and the licensed nurse who completed the form. Further medical record review for Resident 9 did not show an informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails, nor completed an entrapment assessment. On 5/4/23 at 0837 hours, an interview was conducted with CNA 4. CNA 4 stated Resident 9 used the bed side rails to prevent Resident 9 from falling and to aide in turning when repositioning. On 5/4/23 at 0856 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 9 used the bed side rails to help in turning from side to side. On 5/4/23 at 1050 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the facility did not have an entrapment assessment, orders for side rails, nor informed consent for the use of the side rails. 2. On 5/2/23 at 0842 hours, 5/3/23 at 0806 hours, and 5/4/23 at 0818 hours, Resident 529 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 529 was initiated on 5/2/23. Resident 529 was readmitted to the facility on [DATE]. Review of Resident 529's H&P examination dated 4/9/23, showed Resident 529 had the capacity to understand and make decisions. Review of Resident 529's MDS dated [DATE], showed Resident 529 required extensive assistance of one staff for bed mobility. Review of Resident 529's Order Summary Report dated April and May 2023 did not show the physician's order for Resident 529's bilateral half bed side rails use. Review of Resident 529's Restraint Assessment undated, did not show the indication for the use of Resident 529's bilateral half bed side rails, the use of least restrictive measures, nor the licensed nurse who completed the form. Further medical record review for Resident 529 did not show documentation of an informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails, nor completed an entrapment assessment. On 5/3/23 at 0806 hours, an interview was conducted with Resident 529. Resident 529 stated she used the bed side rails to grab onto for turning side to side. Resident 529 was asked if she was able to put down the side rails and stated no. On 5/4/23 at 1032 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the facility did not have an entrapment assessment, physician's order, and informed consent for the use of the side rails. 3. On 5/2/23 at 1413 hours, Resident 24 was observed to be sitting at the edge of the bed with half side rails elevated. Medical record review for Resident 24 was initiated on 5/4/23. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's MDS dated [DATE], showed Resident 24 had severe cognitive impairment. Review of Resident 24's H&P examination dated 2/5/23, showed Resident 24 with diagnosis of recurrent seizures (a sudden, uncontrolled burst of electrical activity in the brain which can cause changes in behavior, movement, feelings, and levels consciousness). Review of the Resident 24's Order Summary Report dated May 2023, showed a physician's order dated 3/2/23, may have bilateral upper side rails up while in bed for mobility and repositioning. Further medical record review for Resident 24 did not show documentation of the entrapment assessment and informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails. On 5/4/23 at 0843 hours, an interview was conducted with RNA 1. RNA 1 stated Resident 24 was mostly independent and preferred to be on his own. On 5/4/23 at 0900 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 24 was mostly independent and preferred to be on his own. CNA 1 stated she was not aware the side rails were a form of restrain when elevated. On 5/4/23 at 1032 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the facility did not have an entrapment assessment and informed consent for the use of the side rails. 4. On 5/2/23 at 0906 hours, Resident 26 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 26 was initiated on 5/2/23. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's MDS dated [DATE], showed Resident 26 required extensive assistance of one staff for bed mobility. Review of Resident 26's Order Summary Report dated May 2023, showed a physician's order dated 3/28/23, may have bilateral upper side rails up while in bed for increased bed mobility and repositioning Review of Resident 26's Restraint Assessment undated, did not show the indication for the use of Resident 26's bilateral half bed side rails, the use of least restrictive measures, and the licensed nurse who completed the form. Further medical record review for Resident 26 did not show documentation of the entrapment assessment and informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails. On 5/4/23 at 0900 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 26 was confused and hard of hearing. CNA 1 stated Resident 26 used the elevated half side rails for repositioning. On 5/4/23 at 1032 hours, an interview was conducted with the DON. The DON stated the residents with side rails were the ones who repositioned themselves. The DON verified the above findings and stated the Restraint Assessments should be dated and the licensed nurse who completed the assessment should have signed the form. The DON further stated the assessment for entrapment was not performed. 5. On 5/2/23 at 0834, 5/3/23 at 0809 hours, and 5/3/23 at 1345 hours, Resident 8 was observed in bed with bilateral side rails elevated. Medical record review for Resident 8 was initiated on 5/2/23. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's MDS dated [DATE], showed Resident 8 had severe cognitive impairment and required extensive assistance of two persons for bed mobility. Review of Resident 8's Order Summary Report dated May 2023 showed a physician's order dated 2/25/23, may have side rails up while in bed for increased mobility and repositioning. Further medical record review for Resident 8 did not show documentation of entrapment assessment and informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails. On 5/2/23 at 0834 hours, an interview was conducted with CNA 4. CNA 4 stated the resident did not use the side rails and the side rails were used to prevent Resident 8 from falling. On 5/4/23 at 1023 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the residents with side rails were for turning and repositioning. The DON further stated there were no entrapment assessments and no specific form to indicate there was an informed consent for the use of side rails.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirement were met in the kitchen as evidenced by: * The facility failed to ensure the kitchen staff performed proper hand hygiene. * The facility failed to ensure the expired food items in the kitchen refrigerator were discarded and food items stored in the kitchen refrigerator did not belong to the staff. * The facility failed to ensure the blender was air dried. * The facility failed to ensure the aprons worn during food production were clean. * The facility failed to ensure the cutting board was in sanitary condition. * The facility failed to ensure the cleaning cloth was stored in a sanitizing bucket in between uses. * The facility failed to ensure the food preparation sink had an air gap. These failures had the potential to cause food-borne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of residents completed by the facility dated 5/2/23, showed 26 of 28 residents in the facility received food prepared in the kitchen. 1. According to the FDA Food Code 2022, Section 2-301.12 Cleaning Procedure. (A) Except as specified in (D) of this section, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms, including surrogate prosthetic devices for hands or arms for at least 20 seconds, using a cleaning compound in a HANDWASHING SINK that is equipped as specified under § 5-202.12 and Subpart 6-301. According to the FDA Food Code 2022, Section 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: . (E) After handling soiled EQUIPMENT or UTENSILS. Review of the facility's P&P titled Food Preparation and Service revised 4/2019 showed food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illnesses. Review of the facility's In-service Record provided to the dietary staff conducted on 4/13/22, showed a topic for handwashing. The in-service material showed when should handwashing be done: after handling soiled equipment, utensils, rags, mops, or garbage and how to wash hands correctly: wash for about 20 seconds. On 5/2/23 at 0902 hours, an observation in the kitchen was conducted. [NAME] 1 was observed on the dirty side of dish machine loading dirty dishes onto the dish rack, then proceeded to take the clean trays without washing her hands. On 5/3/23 at 0914 hours, an observation in the kitchen was conducted. [NAME] 1 was observed at the handwashing sink. [NAME] 1 was observed washing her hands with soap for only three seconds. On 5/5/23 at 1100 hours, an interview with [NAME] 1 was conducted. When asked regarding handwashing, [NAME] 1 stated she did not know how long she was supposed to wash her hands. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN expected the kitchen staff to perform proper hand washing. 2. Review of the facility's P&P titled Refrigerators and Freezers revised 12/2014 showed the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. The supervisors will be responsible for ensuring food items in the pantry, refrigerators, and freezers are not expired or past perish dates. Review of the facility's document titled Refrigerated Storage Guide undated, showed the non-dairy creamer should be stored for one week or longer per manufacturers date. Review of the facility's In-service Records with dietary staff conducted on 1/19/23, showed an in-service topic on no personal food in the kitchen refrigerator. The in-service material showed a P&P for Employee Meals showing food brought by employees from outside the facility shall not be kept in the facility's refrigerator in the kitchen nor prepared or reheated in the facility's kitchen and employees bringing food from outside the facility may not keep their food in the refrigerator used to store food for the residents. They may bring food which can be kept in the employee lounge and food may be kept in a refrigerator supplied for the employees in the employee lounge. On 5/2/23 at 0812 hours, an inspection of the kitchen refrigerator was conducted and observed the following in the kitchen refrigerator: - a bottle of hazelnut flavored non-dairy coffee creamer labeled with Resident 15's name and dated 4/13/23, and - a bottle of french vanilla flavored non-dairy coffee creamer labeled with a first name and dated 4/17/23. The bottle of non-dairy coffee creamers showed to keep refrigerated and for best quality, use within 14 days of opening. On 5/2/23 at 0813 hours, a concurrent observation and interview with [NAME] 1 was conducted. After showing the non-dairy coffee creamer label to [NAME] 1, [NAME] 1 verified the dates when the non-dairy coffee creamers were opened and acknowledged it was stored in the kitchen refrigerator beyond 14 days. On 5/2/23 at 1059 hours, a concurrent observation and interview was conducted with the Certified Dietary Manager. The bottles of non-dairy coffee creamer were not observed inside the kitchen refrigerator. The Certified Dietary Manager acknowledged the bottles of non-dairy coffee creamers were stored in the refrigerator for more than 14 days after opening and the Certified Dietary Manager discarded the bottles. On 5/4/23 at 1054 hours, a follow-up interview with the Certified Dietary Manager was conducted. When asked to verify who the bottle of french vanilla flavored coffee creamer belong to, the Certified Dietary Manager verified the french vanilla flavored non-dairy creamer belonged to the Business Office Manager. The Certified Dietary Manager verified the employee's food items should not be stored in the kitchen refrigerator. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified the expired food in the kitchen refrigerator should be discarded. 3. According to the FDA Food Code 2022, Section 4-901.11 Equipment and Utensils, Air-Drying Required. After cleaning and sanitizing, and utensils: Equipment (A) Shall be air-dried . Review of the facility's P&P titled Sanitation revised 10/2008 showed food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. On 5/2/23 at 0842 hours, the blender was observed on the drying cart with the cover on. The blender was observed with water inside. On 5/2/23 at 0900 hours, a concurrent observation and interview with the Certified Dietary Manager was conducted. When asked if the blender should be air dried with the cover on, the Certified Dietary Manager acknowledge it should be air dried with the cover off. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified kitchen equipment should be air dried. 4. Review of the facility's P&P titled Food Preparation and Services revised 4/2019 showed food and nutrition services employees prepare and serve the food in a manner that complies with safe food handling practices and food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Review of the facility's In-service Records with dietary staff conducted on 7/14/22, showed an in-service topic of Personal Hygiene. The in-service attached material showed under proper attire to use clean apron and change aprons when soiled. On 5/2/23 at 0856 hours, an observation of the janitor's closet/employee storage located in the kitchen was conducted. One multi-colored apron and one black apron were observed hanging on the wall touching a dustpan. On 5/2/23 at 0900 hours, a concurrent observation and interview with the Certified Dietary Manager was conducted. The Certified Dietary Manager verified the aprons were stored in the janitor's closet/employee's storage touching the dustpan. On 5/2/23 at 1015 hours, an observation of janitor's closet/employee storage was conducted. The multi-colored and black aprons were not observed in the closet. On 5/2/23 at 1017 hours, an observation in the kitchen was conducted. The Certified Dietary Manager was observed wearing the multi-colored apron washing dishes and [NAME] 2 was wearing a black apron prepping food for lunch. An interview with [NAME] 2 was conducted. When asked where [NAME] 2 got the black apron she was wearing, [NAME] 2 stated she got the black apron from the storage. On 5/4/23 at 1054 hours, an interview with the Certified Dietary Manager was conducted. When asked regarding the two aprons touching the dustpan in the employee storage, the Certified Dietary Manager acknowledge the aprons were dirty and should not be worn during the food production. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified the aprons worn in kitchen should be taken home every day and washed. 5. According to the FDA Food Code 2022, Section 4-501.12 Cutting Surfaces. Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced. Review of the facility's P&P titled Sanitization revised 10/2008 showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracked and chipped areas that may affect their use or proper cleaning. On 5/3/23 at 0913 hours, an observation in the kitchen was conducted. A green cutting board was observed with rough surfaces. On 5/3/23 at 0919 hours, a concurrent observation and interview with the Certified Dietary Manager was conducted. The Certified Dietary Manager acknowledged the green cutting board had rough surfaces and needed to be replaced. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified the cutting board should have a cleanable smooth surface. 6. According to the FDA Food Code 2022, Section 3-304.14 Wiping Cloths, Use Limitation . (B) Cloths in-use for wiping counters and other equipment surfaces shall be: (1) Held between uses in a chemical sanitizer solution . Review of the facility's P&P titled Sanitization revised 10/2008 showed between uses, cloth and towels used to wipe kitchen surfaces will be soaked in containers filled with approved sanitizing solution. Sanitizing solution will be changed at least once per shift or if solution becomes cloudy or visibly dirty. On 5/3/23 at 1007 hours, an observation in the kitchen was conducted. A cleaning cloth was observed on top of the ice cream freezer. When the kitchen staff was asked if the cleaning cloth was supposed to be on top of the freezer, [NAME] 1 was observed taking the cleaning cloth and placed it on top of the food preparation table. On 5/3/23 at 1008 hours, a concurrent observation and interview with [NAME] 2 was conducted. [NAME] 2 stated cleaning cloth should be in the red sanitizing bucket when not in use. [NAME] 2 was observed taking the cleaning cloth from the food preparation table and placed the cleaning cloth in the dirty laundry area. On 5/3/23 at 1018 hours, an interview with the Certified Dietary Manager was conducted. The Certified Dietary Manager stated the cleaning cloth should be soaked in the red bucket sanitizing solution when not in use. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified cleaning cloths should be stored in red bucket sanitizing solution in between uses. 7. According to the FDA Food Code Annex 2022: 5-402.11 Backflow Prevention. Improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces. According to the FDA Food Code 2022, Section 5-402.11 Backflow Prevention. Except as specified in (B), (C), and (D) of this section, a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed. On 5/3/23 at 1010 hours, a concurrent observation and interview was conducted with the kitchen staff. Cooks 1 and 2 verified the rinse sink was used as food preparation sink. The under-sink pluming was observed without an air gap. On 5/3/23 at 1023 hours, an interview with Certified Dietary Manager was conducted. The Certified Dietary Manager verified the rinse sink was being used as food preparation sink. On 5/3/23 at 1515 hours, a concurrent observation and interview with the Administrator was conducted. The Administrator acknowledged the rinse sink did not have an air gap. The Administrator stated the facility was aware and was working on getting the sink fixed. The facility was unable to provide documentation on how the facility was fixing the food preparation sink air gap. On 5/3/23 at 1530 hours, an interview with the Maintenance Staff was conducted. When asked if he was aware of the rinse sink had no air gap, the Maintenance Staff stated he was made aware this morning. On 5/4/23 at 1118 hours, an interview with the Maintenance Supervisor was conducted. When asked if he was aware of the rinse sink had no air gap, the Maintenance Supervisor stated he was made aware this morning. On 5/4/23 at 1321 hours, a telephone interview with the RDN was conducted. The RDN verified the food preparation sink should have an air gap.

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the essential equipment was maintained according to the manufacturer's recommendations. * The facility failed to ensure the ice machine cleaning instructions were followed. This failure had the potential to affect the equipment not functioning in the way it was intended which could affect the health status of the residents. Findings: Review of the facility's P&P titled Ice Machines and Storage Chest revised 1/2012 showed the facility has established procedures for cleaning and disinfecting the ice machines and ice storage chests which adhere to the manufacturer's instructions. Review of the facility's P&P titled Sanitization revised 10/2008 showed the ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy. Review of the document titled WS 12000 Annual PM Guide provided by the facility showed the WS 12000 Unit needs preventive maintenance every year and to follow the appropriate instructions. Under Part 1: Sanitizing the Unit, it showed list of items needed including hydrogen peroxide. On 5/3/23 at 0919 hours, an interview with the Certified Dietary Manager was conducted. When asked about the facility's ice machine, the Certified Dietary Manager showed an ice maker/water dispenser machine in the dining room which was currently not working. On 5/3/23 at 1337 hours, an interview was conducted with the Certified Dietary Manager. When asked for the ice machine maintenance log, the Certified Dietary Manager was unable to provide the log for the ice machine/water dispenser. On 5/4/23 at 0940 hours, a concurrent observation and interview with the Vendor Personnel was conducted. The Vendor Personnel stated the ice machine/water dispenser unit required yearly cleaning and filter changed. The Vendor Personnel stated per company record, the last ice machine/water dispenser maintenance was done on 2/5/22. The Vendor Personnel showed the bottles of Nu-Calgon sanitizing solution and Manitowoc ice machine sanitizer being used to clean the ice machine. The sanitizing solution samples provided by the Vendor Personnel did not match the solution in the WS 12000 Annual PM Guide. On 5/4/23 at 0940 hours, during the inspection of ice machine/water dispenser conducted by the Vendor Personnel, the Administrator stated the last ice machine maintenance was not 2/5/22, however, the Administrator was unable to provide documentation to show when the ice machine/water dispenser was cleaned.

CONCERN (E)

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

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the regular inspection of all the bed frames, mattresses, and side rails as part of the regular maintenance program to identify areas of possible entrapment for seven of 14 final sampled residents (Residents 5, 8, 9, 21, 24, 26, and 529). This failure had the potential to negatively impact the residents resulting to entrapment, serious injuries, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety revised 12/2007 showed to try to prevent deaths/injuries from the beds and related equipment (including the frames, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote that the following approaches: - Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; - Review that gaps within the bed system are within the dimensions established by the FDA; - Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; - Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). The maintenance department shall provide a copy of inspections to the Administrator and report results to the QA Committee for appropriate action. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 1. On 5/2/23 at 0838 hours and 5/3/23 at 0756 hours, Resident 9 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 9 was initiated on 5/2/23. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's MDS dated [DATE], showed Resident 9 was moderate cognitively impaired and required extensive assistance on two staff for bed mobility. Further medical record review for Resident 9 did not show informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails nor completed an entrapment assessment. 2. On 5/2/23 at 0842 hours, 5/3/23 at 0806 hours, and 5/4/23 at 0818 hours, Resident 529 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 529 was initiated on 5/2/23. Resident 529 was readmitted to the facility on [DATE]. Review of Resident 529's H&P examination dated 4/9/23, showed Resident 529 had the capacity to understand and make decisions. Review of Resident 529's MDS dated [DATE], showed Resident 529 required extensive assistance on one staff for bed mobility. Further review of Resident 529's medical record did not show an informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails nor completed an entrapment assessment. 3. On 5/2/23 at 1413 hours, Resident 24 was observed sitting at the edge of the bed with bilateral half side rails elevated. Medical record review for Resident 24 was initiated on 5/4/23. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's MDS dated [DATE], showed Resident 24 had severe cognitive impairment. Review of Resident 24's H&P examination dated 2/5/23, showed Resident 24 had diagnosis of recurrent seizures. Review of the Resident 24's Order Summary Report dated May 2023 showed a physician's order dated 3/2/23, may have bilateral upper side rails up while in bed for mobility and repositioning. Further review of Resident 24's medical record did not show documentation of informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails nor completed an entrapment assessment. 4. On 5/2/23 at 0906 hours, Resident 26 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 26 was initiated on 5/2/23. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's MDS dated [DATE], showed Resident 26 required one staff extensive assistance for bed mobility. Review of Resident 26's Order Summary Report dated May 2023, showed a physician's order dated 3/28/23, may have bilateral upper side rails up while in bed for increased bed mobility and repositioning Further review of Resident 26's medical record did not show documentation of an informed consent from the resident and/or representative for the potential risks and benefits of the use of bed side rails nor completed an entrapment assessment. 5. On 5/2/23 at 0834 hours and 5/3/23 at 0809 hours, Resident 8 was observed in bed with bilateral side rails elevated. Medical record review for Resident 8 was initiated on 5/2/23. Resident 8 was readmitted to the facility on [DATE]. Review of Resident 8's MDS dated [DATE], showed Resident 8 had severe cognitive impairment and required extensive assistance of two person for bed mobility. Review of Resident 8's Order Summary Report dated May 2023 showed a physician's order dated 2/25/23, may have side rails up while in bed for increased mobility and repositioning. Further review of Resident 8's medical record did not show documentation of an informed consent from the resident and/or representative for the potential risks and benefits of the use of the bed side rails nor completed an entrapment assessment. 6. Medical record review for Resident 5 was initiated on 5/2/23. Resident 5 was admitted to the facility on [DATE]. On 5/2/23 at 0834 hours during initial tour of the facility, Resident 5 was observed asleep in bed with the upper bilateral side rails elevated. On 5/3/23 at 1136 hours, during an observation, Resident 5 was observed in bed with upper bilateral side rails. Review of Resident 5's H&P examination dated 12/24/22, showed Resident 5 did not have the capacity to understand or make decisions. Review of Resident 5's MDS dated [DATE], showed Resident 5 required total dependence on staff for bed mobility and required more than two staff for assistance. Review of Resident 5's Physician Orders showed an order dated 1/27/23 for bilateral upper side rails while in bed for mobility and repositioning. 7. Medical record review for Resident 21 was initiated on 5/2/23. Resident 21 was admitted to the facility on [DATE], with a diagnosis of dementia. On 5/2/23 at 0815 hours during an initial tour of the facility, Resident 21 was observed with the upper bilateral side rails elevated. On 5/3/23 at 0800 hours during an observation, Resident 21 was observed asleep in bed with the upper bilateral side rails elevated. Review of Resident 21's H&P examination dated 12/01/22, showed Resident 21 did not have the capacity to understand or make decisions. Review of Resident 21's MDS dated [DATE], showed Resident 5 required extensive assistance from staff for bed mobility. Review of Resident 21's Physician Orders showed an order dated 11/21/23, for bilateral upper side rails while in bed for mobility and repositioning. Further review of the facility document showed these residents' beds with side rails use were not regularly inspected for possible entrapment. On 5/4/23 at 1032 hours, an interview was conducted with the DON. The DON was asked if any measurements were done for the beds with side rails nor an entrapment assessment was completed. The DON stated she had not seen any form done for the measurements of the bed nor entrapment assessments. On 5/4/23 at 1108 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he measured the side rails and bed only once before the pandemic. The Maintenance Supervisor was asked the process of installing the side rail in the bed. The Maintenance Supervisor stated the DSD before gave him a list of residents needed the side rails installed in the bed. Then, the Maintenance Supervisor stated he would measure the bed per the guidelines, document what was given from the DSD before, and would install the side rails to the bed. The Maintenance Supervisor further stated there were new beds purchased since the last measurements of the other beds in the building, but he was unable to locate the new beds in the building. The Maintenance Director was asked to provide the documents to show he measured the beds to prevent entrapment, however, he stated the previous DSD had them and was not able to show any documentations of the measurements of the beds. On 5/4/23 at 1124 hours, an interview was conducted with the DSD/IP. The DSD/IP stated she had not dealt with the side rails in the facility. The DSD/IP was asked if she could provide the records for the side rail assessments. The DSD/IP stated she would not keep the resident's assessments in her file. The DSD/IP further stated the side rail assessment should be in each resident's medical record and if the assessments were not found in resident's medical record, then there were no documents completed.

MINOR (B)

Minor Issue - procedural, no safety impact

Notification of Changes (Tag F0580)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure facility staff identified and notified the physician and family or responsible party of Resident 15's change of condition related to low blood pressure. This failure had the potential for Resident 15 to not receive the appropriate care and services to treat medical conditions. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 showed the facility will promptly notify the resident, his or her attending physician, and resident representative of changes in the resident's medical/mental condition. Medical record review of Resident 15 was initiated on 6/15/23. Resident 15 was admitted to the facility on [DATE]. Resident 15 had diagnoses which included hypertension (high blood pressure). Review of Resident 15's Care Plan dated 1/13/23 showed a care plan problem addressing hypertension. One of hte care plan interventions was to check the blood pressures prior to the medication administration and notify the physician of any significant results. Review of Resident 15's untitled document showed on 5/22/23 at 2111 hours, the resident's blood pressure reading was 71/49 mmHg (normal blood pressure: 128/50 mmHg). Review of Resident 15 's Progress Notes for May 2023 showed no documented evidence Resident 1's change of condition was identified. Further review of progress notes did not show the physician and responsible party, or family member were notified of Resident 1's low blood pressure reading. Review of the facility document titled In-Service Sign in Sheet dated 5/11/23, with the subject titled Change of Condition did not show the signature of LVN 3. On 6/15/23 at 1455 hours, a concurrent interview and record review was conducted with the DON. The DON verified the above findings. The DON stated blood pressure reading of 71/49 mmHg was a change of condition for Resident 15. The DON stated LVN 3 should have rechecked the resident's blood pressure to confirm, notified the physician, the resident's responsible party, and called 911 if appropriate. The DON stated facility provided the in-service to all licensed staff regarding resident change of condition on 5/11/23, however; the DON was not able to provide documented evidence if LVN 3 had received the in-service. On 6/16/23 at 1720 hours, the Administrator, DON, and QA/IP were informed and acknowledged the above findings

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• No fines on record. Clean compliance history, better than most California facilities.

Concerns

• 67 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade C (55/100). Below average facility with significant concerns.

Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.

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About This Facility

What is Stanley Healthcare Center's CMS Rating?

CMS assigns STANLEY HEALTHCARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Stanley Healthcare Center Staffed?

CMS rates STANLEY HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes.

What Have Inspectors Found at Stanley Healthcare Center?

State health inspectors documented 67 deficiencies at STANLEY HEALTHCARE CENTER during 2023 to 2025. These included: 1 that caused actual resident harm, 53 with potential for harm, and 13 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Stanley Healthcare Center?

STANLEY HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PROGRESSIVE HEALTH CARE CENTERS, a chain that manages multiple nursing homes. With 30 certified beds and approximately 22 residents (about 73% occupancy), it is a smaller facility located in WESTMINSTER, California.

How Does Stanley Healthcare Center Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, STANLEY HEALTHCARE CENTER's overall rating (3 stars) is below the state average of 3.1 and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Stanley Healthcare Center?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Stanley Healthcare Center Safe?

Based on CMS inspection data, STANLEY HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Stanley Healthcare Center Stick Around?

STANLEY HEALTHCARE CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.

Was Stanley Healthcare Center Ever Fined?

STANLEY HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Stanley Healthcare Center on Any Federal Watch List?

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

Facility Details

Beds: 30
Avg. Residents: 22
Occupancy: 74.3%
Ownership: For profit - Limited Liability company
Chain: PROGRESSIVE HEALTH CARE CENTERS
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
1 Actual Harm citation: -5
67 Deficiencies: -10
Final Score: 55/100

Nearby Alternatives

VICTORIA HEALTHCARE AND REHABI... 5-star PACIFIC HAVEN SUBACUTE AND HEA... 5-star GREENFIELD CARE CENTER OF FULL... 5-star

View all in WESTMINSTER →

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555651