How many inspection deficiencies does BAYSHIRE YORBA LINDA POST-ACUTE have?

BAYSHIRE YORBA LINDA POST-ACUTE has 56 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at BAYSHIRE YORBA LINDA POST-ACUTE?

BAYSHIRE YORBA LINDA POST-ACUTE has a three-star staffing rating from CMS with 0.59 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 BAYSHIRE YORBA LINDA POST-ACUTE located?

BAYSHIRE YORBA LINDA POST-ACUTE is located in YORBA LINDA, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does BAYSHIRE YORBA LINDA POST-ACUTE have?

BAYSHIRE YORBA LINDA POST-ACUTE has 45 certified beds.

Who owns BAYSHIRE YORBA LINDA POST-ACUTE?

BAYSHIRE YORBA LINDA POST-ACUTE is a for profit - individual facility and is part of the BAYSHIRE SENIOR COMMUNITIES chain.

How does BAYSHIRE YORBA LINDA POST-ACUTE compare to other nursing homes?

BAYSHIRE YORBA LINDA POST-ACUTE has a 4-star overall rating, placing it above average compared to other nursing homes in CA. Higher-rated facilities typically have better inspection results and staffing levels.

BAYSHIRE YORBA LINDA POST-ACUTE

Name: BAYSHIRE YORBA LINDA POST-ACUTE
Address: 17803 IMPERIAL HIGHWAY, YORBA LINDA, CA, 92886, US
Telephone: (714) 777-9666
Rating: 4.0

17803 IMPERIAL HIGHWAY, YORBA LINDA, CA 92886 · (714) 777-9666

For profit - Individual 45 Beds BAYSHIRE SENIOR COMMUNITIES Data: November 2025

Trust Grade

68/100

#293 of 1155 in CA

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Last Inspection: April 2025

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

Overview

Bayshire Yorba Linda Post-Acute has a Trust Grade of C+, indicating it is slightly above average but may not be the best choice for everyone. It ranks #293 out of 1,155 facilities in California, placing it in the top half, and #20 out of 72 in Orange County, meaning there are only a few local options that are better. The facility is improving, with the number of issues found decreasing from 30 in 2024 to 15 in 2025. Staffing is average with a 3/5 star rating and a turnover rate of 43%, which is similar to the state average. However, there have been some concerning incidents, including failures in kitchen sanitation, such as expired food items not being discarded and improper food labeling, which could risk foodborne illnesses for residents.

Trust Score: C+
In California: #293/1155
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 43% turnover. Near California's 48% average. Typical for the industry.
Penalties: $4,368 in fines. Higher than 89% of California facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
Violations: 56 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★★☆

4.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★★

5.0

Care Quality

★★★☆☆

3.0

Inspection Score

↔

Stable

2024: 30 issues

2025: 15 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (43%)
5 points below California average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

Staff Turnover: 43%

Near California avg (46%)

Typical for the industry

Federal Fines: $4,368

Below median ($33,413)

Minor penalties assessed

Chain: BAYSHIRE SENIOR COMMUNITIES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 56 deficiencies on record

Apr 2025 14 deficiencies

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to develop the plan of care to reflect the individual care needs for one of 13 final sampled residents (Resident 25). * The facility failed to develop a care plan problem to address Resident 25's spinal precautions and use of LSO brace while out of bed. This failure posed the risk of not providing appropriate, consistent, or individualized care to the resident. Findings: Medical record review of Resident 25 was initiated on 4/2/25. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 3/31/25, showed one of Resident 25's diagnosis was S/P lumbar fusion. Review of Resident 25's PT and OT Evaluation and Treatment notes dated 4/1/25, showed the section for Precaution/Contraindication showing to provide spinal precautions and LSO brace when out of bed. Review of Resident 25's Order Summary Report showed a physician's order dated 4/1/25, for the LSO brace when out of bed. Review of Resident 25's Nursing Progress Note dated 4/1/25, showed a documentation by RN 1 included the following admitting diagnoses: spinal stenosis, lumbar region with neurogenic claudication, encounter for Orthopedic Care, and fusion of the spine, and lumbar region. Review of Resident 25's Care Plan Report for ADL care, Pain, PT, and OT did not include the interventions to provide Resident 25 the spinal precautions, and/or use the use of LSO brace when out of bed. On 4/3/25 at 1055 hours, an interview and concurrent medical record review was conducted with the OT and PT staff regarding Resident 25's plan of care. The OT and PT staff verified Resident 25 had a lumbar fusion, should be on the spinal precautions, and to use the LSO brace when out of bed. The OT and PT staff verified and acknowledged Resident 25's care plan did not include the interventions to provide spinal precaution and/or the used of the LSO brace when out of bed. On 4/4/25 at 957 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 stated Resident 25 used the back brace when getting out of bed and no other precautions were needed or instructed during the transfers or in bed mobility of the resident. On 4/4/25 at 1002 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 was in Resident 25's room and observed transferring Resident 25 from the bed to the chair weighing scale. CNA 4 was asked if he had to do any precautions during Resident 25's transfers, CNA 4 stated, no, the resident is a lot better than before. On 4/7/25 at 1330 hours, an interview was conducted with the DON and Administrator. The DON and Administrator was made aware and acknowledged the above findings.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to revise the residents' comprehensive care plans to address the use of side rails for three of four final sampled residents (Residents 16, 17, and 339) reviewed for the side rail use. * The facility failed to ensure the plan of care for Residents 16, 17, and 339 addressing the use of the side rails were revised to show the accurate least restrictive interventions prior to the use of side rails. The residents' plan of care showed the grab rails and quarter-sized rails were used as the least restrictive interventions prior to the use of the side rails. These failures posed the risk of not providing an individualized care for Residents 16, 17, and 339 related to the use of the side rails. Findings: 1. Medical record review for Resident 16 was initiated on 4/1/25. Resident 16 was readmitted to the facility on [DATE]. Review of Resident 13's Order Summary Report showed a physician's order dated 3/13/25, for the bilateral deluxe assist bed handles up while in bed for turning and repositioning. Review of Resident 13's Skilled Nursing - admission Initial Eval - V13 dated 3/13/25, under the Side/Bed Rail Evaluation section, showed the alternative attempted and/or considered was an adjustable bed (low-mid height). Review of Resident 13's plan of care showed a care plan problem dated 3/14/25, addressing the use of the grab bars for the resident's mobility. The interventions/tasks included for the grab bars to both sides of the bed, and the side/bed rails quarter size were used as the least restrictive devices for the bed mobility, turning, positioning and transfers to reduce the functional decline. 2. Medical record review for Resident 17 was initiated on 4/1/25. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed a physician's order dated 2/17/25, for the bilateral deluxe assist bed handles up while in bed for turning and repositioning. Review of Resident 17's Skilled Nursing - admission Initial Eval - V13 dated 2/17/25, under the Side/Bed Rail Evaluation section, showed the alternative attempted and/or considered was the use of the bedside mats. Review of Resident 17's plan of care showed a care plan problem dated 2/17/25, addressing the use of the grab bars for mobility. The interventions/tasks included for the grab bars to both sides of the bed, and the quarter size side/bed rails were used as the least restrictive devices for the bed mobility, turning, positioning and transfers to reduce the functional decline. 3. Medical record review for Resident 339 was initiated on 4/1/25. Resident 339 was admitted to the facility on [DATE]. Review of Resident 339's Order Summary Report showed a physician's order dated 3/31/25, for the bilateral deluxe assist bed handles up while in bed for turning and repositioning. Review of Resident 339's Skilled Nursing - admission Initial Eval - V13 dated 3/31/25, under the Side/Bed Rail Evaluation section, showed the alternative attempted and/or considered was the bedside mats. Review of Resident 339's plan of care showed a care plan problem dated 4/1/25, addressing the use of the grab bars for mobility. The interventions tasks included for the grab bars to both sides of the bed, and the quarter size side/bed rails were used as the least restrictive devices for the bed mobility, turning, positioning and transfers to reduce the functional decline. On 4/7/25 at 1005 hours, an interview and concurrent medical record review for Residents 16, 17, and 339 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the admitting nurse initiated the care plan for Residents 16, 17, and 339 related to the use of the side rails. RN 1 was not sure why the interventions related to the use of the grab rails were the same for Residents 16, 17, and 339, and why the grab rails and side/bed rails were documented in the care plan as the least restrictive devices for bed mobility, turning, positioning and transfers.

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 ensure the necessary respiratory care and services were provided to three of 13 final sampled residents (Residents 1, 2, and 19) reviewed for the respiratory care. * The facility failed to ensure Resident 19 received the oxygen as per the physician's order. * The facility failed to ensure Residents 1 and 2 were provided with the No Smoking/Oxygen in Use sign indicating the oxygen use continuously. These failures had the potential to negatively affect the residents' well-being and posed the risk for safety due to the residents' use of the oxygen continuously. Findings: 1. Medical record review for Resident 19 was initiated on 4/1/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's H&P examination dated 1/10/25, showed Resident 19 had the capacity to understand and make decisions. Review of Resident 19's Order Summary Report dated 4/2/25, showed a physician's order dated 1/14/25, to administer oxygen therapy continuously at 2 liters per minute via nasal cannula and may titrate the oxygen up to 5 liters per minute to maintain the oxygen saturation levels greater than 90% every shift for shortness of breath. On 4/1/25 at 0830 hours, an observation was conducted for Resident 19. Resident 19 was observed receiving the oxygen therapy at 1.5 liters per minute continuously via nasal cannula. On 4/1/25 at 1000 hours, an observation and concurrent interview was conducted with RN 2. RN 2 was summoned to Resident 19's room. Resident 19 was observed receiving the oxygen therapy at 1.5 liters per minute continuously via nasal cannula. RN 2 verified the findings. On 4/1/25 at 1010 hours, a follow-up interview and concurrent medical record review was conducted with RN 2. RN 2 stated Resident 19 should have been receiving the oxygen therapy at 2 to 5 liters per minute via nasal cannula continuously. 2. Review of the facility's P&P titled Oxygen Administration revised October 2010 showed the purpose of this procedure is to provide guidance for the safe oxygen administration. The section for Equipment and Supplies necessary when performing this procedure included the No Smoking/Oxygen in Use sign and the Steps in the Procedure showed to place an Oxygen in Use sign on the outside of the resident's room entrance door, and close the door. Medical record review for Resident 2 was initiated on 4/1/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary report dated 4/3/25, showed a physician's order dated 3/17/25, to administer oxygen therapy continuously at 2 liters per minute via nasal cannula and may titrate the oxygen up to 5 liters per minute to maintain the oxygen saturation levels greater than 90% every shift for shortness of breath. On 4/1/25 at 0800 hours, an observation was conducted for Resident 2. Resident 2 was observed receiving the oxygen therapy at 3 liters per minute continuously via nasal cannula. There was no No Smoking/Oxygen in Use sign placed on the outside of the room entrance. On 4/1/25 at 1010 hours, an observation and concurrent interview was conducted with RN 2. RN 2 was summoned to Resident 2's room. Resident 2 was observed receiving the oxygen therapy at 3 liters per minute continuously via nasal cannula. There was no signage of No Smoking/Oxygen in Use present. RN 2 stated there should have been a signage indicating the oxygen use as Resident 2 used the oxygen continuously. RN 2 verified the findings. 3. On 4/1/25 at 0844 hours, during the initial tour of the facility, Resident 1 was observed eating breakfast while on bed with head of bed upright position receiving oxygen via nasal canula at 2 liters per minute via oxygen concentrator. There was no No Smoking/Oxygen in Use sign placed on the entrance door of the resident's room. Medical record review for Resident 1 was initiated on 4/2/25. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 1's medical diagnoses included COPD and other specified symptoms involving the circulatory and respiratory systems. Review of Resident 1's Order Summary Report dated 4/2/25, showed a physician's order dated 3/21/25, for oxygen therapy continuously at 2 liters per minute via nasal canula and may titrate the oxygen up to 5 liters per minute to maintain the oxygen saturation levels greater than 90% every shift for shortness of breath. On 4/1/25 at 1028 hours, a follow up observation and concurrent interview was conducted with RN 2 for Resident 1. There was no No Smoking/ Oxygen in Use sign observed at the entrance of Resident 1's door. RN 2 verified Resident 1 was on continuous use of oxygen and there was no No Smoking/Oxygen in Use sign placed on the entrance of the door. RN 2 stated all residents on oxygen therapy should have a sign on the entrance of the door. On 4/1/25 at 1040 hours, another follow-up observation and concurrent interview was conducted with the DON for Resident 1. The DON verified the findings and stated there should be a No Smoking/Oxygen in Use signage in the resident's room for all the residents using the oxygen.

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** 2. Review of the facility's P&P titled Controlled Substances revised April 2019 showed the facility complies with all the laws, regulations and other requirements related to the handling, storage, disposal, and documentation of the controlled medications. The controlled substances are reconciled upon the receipt, administration, disposition, and at the end of each shift. The controlled medications are counted at the end of each shift. The nurses coming on duty and the nurses going off duty determine the count together. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately. The P&Ps for monitoring of the controlled medications to prevent the loss, diversion or accidental exposure are periodically reviewed and updated by the director of nursing services and the consultant pharmacist. On 4/2/25 at 1212 hours, a medication cart inspection for Medication Cart 1 was conducted with LVN 1. The Narcotic Binder was reviewed and showed the Narcotic Shift Count sheets had multiple missing nurses' signatures for the incoming and/or outgoing nurses for the following shifts and dates: a. For January 2025: - during the morning shifts on 1/10, 1/12, and 1/14 - 1/19/25; - during the afternoon shifts on 1/15 - 1/16/25, and 1/18 - 1/19/25; and - during the night shifts on 1/1, 1/10, 1/14 - 1/15/25, and 1/19 - 1/20/25. b. For February 2025: - during the morning shifts on 2/4, 2/6, 2/10, 2/18, 2/20, and 2/26/25; - during the afternoon shifts on 2/4, 2/18, 2/26 - 2/27/25; and - during the night shifts on 2/2, 2/6, 2/10, 2/17 - 2/19/25, 2/24, and 2/26/25. c. for March 2025: - during the morning shifts on 3/1, 3/12, 3/14 - 3/15/25, 3/21 - 3/22/25, 3/27, 3/29, and 3/31/25; - during the afternoon shifts on 3/4, 3/10, 3/12, 3/14, 3/15, 3/22, 3/27, 3/29, and 3/31/25; and - during the night shifts on 3/1, 3/22, 3/27, and 3/28/25. LVN 1 verified there were multiple days and shifts in the Narcotic Shift Count sheet with no licensed nurses' signatures from the outgoing and incoming shifts. LVN 1 stated this posed the potential risk of medication errors and drug diversion. On 4/3/25 at 0840 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified the above findings. The DON stated it was important that the controlled drugs were counted and the Narcotic Shift Count sheets were signed to prevent the possible loss and diversion of the controlled drugs. Based on interview, facility record review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to one of 13 final sampled residents (Resident 25) and the proper accounting and safeguarding was performed to prevent loss, or diversion of the controlled medications. * The facility failed to provide the insulin medication (medication used to lower the blood sugar) to Resident 25 as ordered by the physician. * The facility failed to ensure the Narcotic Shift Count sheets were completely signed by the incoming and outgoing licensed nurses assigned to Medication Cart 1. These failures posed the risk to negatively affect the resident's well-being and loss or diversion of the controlled medications. Findings: 1. Review of the facility's P&P titled Administering Medications revised 4/2019 showed the individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method of administration before giving the medications. Medical record review for Resident 25 was initiated on 4/4/25. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Order Summary Report dated 4/2/25, showed a physician's order dated 3/31/25, for Humulin R Injection Solution (used to lower blood sugar) inject subcutaneously before meals as per the following blood sugar levels results: - 71- 150 mg/dl = give 0 unit; - 151-200 mg/dl = give 1 unit; - 201-250 mg/dl = give 3 units; - 251-300 mg/dl = give 4 units; - 301-350 mg/dl = give 5 units; - 351-400 mg/dl = give 7 units; and - 401-999 mg/dl = give 8 units and notify the MD. Review of Resident 25's MAR for April 2025 showed the following: - on 4/1/25 at 0730 hours, the blood sugar level result was 176 mg/dl, with a documented code of 13 (meaning no insulin required), and - on 4/3/25 at 1630 hours, the blood sugar level result was 186 mg/dl, with a documented code of 13. On 4/4/25 at 1053 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 acknowledged and verified the findings. LVN 3 stated she should have administered the insulin medication because Resident 25's fingerstick blood sugar level result was more than 150 mg/dl. On 4/4/25 at 1111 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified and acknowledged the findings and stated, the insulin coverage of 1 unit should have been administered. On 4/7/25 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were made aware and acknowledged the above findings.

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** 2. Review of the facility's P&P titled Psychotropic Medication Use dated July 2022 showed a psychotropic medication is any medication that affects the brain activity associated with the mental processes and behavior. The residents, families, and/or the representatives are involved in the medication management process. The psychotropic medication management includes: the indications for use, dose, duration, adequate monitoring for efficacy and adverse consequences; and preventing , identifying and responding to the adverse consequences. The residents prescribed with the psychotropic medications must be monitored for the behavioral symptoms that support the medical necessity of the medication. The behavior(s) being treated must be clearly defined, documented in the medical record, and monitored per shift or as outlined in the resident's care plan. Medical record review for Resident 4 was conducted on 4/4/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report dated 4/2/25, showed a physician's order dated 2/28/25, for risperidone oral tablet 1 mg one tablet by mouth one time a day for mood disturbance/psychosis features. Review of Resident 4's MAR for March 2025 showed the monitoring for the Anti-Psych Drug Effects every shift for the risperidone medication was discontinued on 3/6/25. On 4/4/25 at 0935 hours, an interview and concurrent medical record review for Resident 4 was conducted with the DON. The DON verified Resident 4's MAR and stated she accidentally discontinued the monitoring of the adverse effects of the risperidone antipsychotic medication, and was not able to resume the order. The DON further stated there should have been a continued monitoring of the adverse effects of the risperidone medication if the resident was still taking the medication. Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five final sampled residents (Residents 4 and 26) reviewed for the unnecessary medications were free from the unnecessary psychotropic medications. * The facility failed to ensure Resident 26's quetiapine (antipsychotic medication) order had the necessary diagnoses to treat a specific condition. * The facility failed to ensure Resident 4 was monitored for the adverse effects related to the use of the risperidone medication (antipsychotic medication). These failures had the potential for Residents 4 and 26 to receive the unnecessary psychotropic medications and negatively affect the residents health. Findings: 1. Review of the facility's P&P titled Psychotropic Medication Use dated July 2022 showed the residents are not prescribed the psychotropic medication unless this medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. Medical record review for Resident 26 was initiated on 4/3/25. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed a physician's order dated 3/3/25, for quetiapine fumarate oral tablet 50 mg give one tablet via GTevery 12 hours for mood swing. Review of Resident 26's MAR for March and April 2025 showed Resident 26 was administered with the quetiapine fumarate oral tablet 50 mg one tablet via GT every 12 hours for mood swing. Review of Resident 26's Drug Regimen Review for March 2025 conducted by the Pharmacy Consultant on 3/26/25, showed the recommendations for Resident 26's other medications. However, the drug regimen review failed to show recommendation if the diagnosis for Resident 26's quetiapine medication was needed to be changed. On 4/4/25 at 1111 hours, interview and concurrent record review was conducted with RN 1. RN 1 stated the new admission diagnosis of medications were obtained from the acute care hospital transfer records and relayed to the physician. The pharmacists and physician would then review the appropriateness of the diagnosis the following day after the resident's admission, and would make the necessary changes as indicated. RN 1 verified the indication for Resident 26's quetiapine medication was for mood swing. RN 1 acknowledged the findings and further stated the mood swing was a behavior manifestation and not a diagnosis. On 4/4/25 at 1330 hours, an interview and concurrent medical record review was conducted with the DON. Resident 26's quetiapine medication use for the diagnosis of mood swing was reviewed with the DON. The DON acknowledged the diagnosis for Resident 26's quetiapine medication was inappropriate and stated, it should have been mood disorder. The DON further stated this order came from the acute care hospital and was not followed up by the physician, admitting nurse, and pharmacy consultant. On 4/7/25 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were made aware and acknowledged the above findings.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. According to National Library of Medicine dated 10/15/17, showed not to split, chew or crush extended release tablets. a. Medical record review for Resident 19 was initiated on 4/1/25. Resident 19 was admitted to the facility on [DATE]. Review of Resident 19's Order Summary Report dated 4/2/25, showed the following physician's orders: - dated 1/11/25: to administer nifedipine (calcium channel blocker) ER tablet 60 mg one tablet by mouth once daily for hypertension, hold if systolic blood pressure less than 105 mmHg. - dated 1/28/25: to administer potassium chloride (mineral) ER tablet 10 meq one tablet by mouth once daily as a supplement in conjunction with Lasix. - dated 3/1/25: to administer apixaban (anticoagulant) 2.5 mg tablet by mouth twice daily for atrial fibrillation. - dated 1/9/25, to monitor for signs/symptoms of anticoagulant complications: blood tinged or blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, severe bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs On 4/2/25 at 0820 hours, during the medication observation, LVN 1 administered one tablet of nifedipine 60 mg tablet ER and one tablet of Potassium Chloride 10 meq ER to Resident 19. However, LVN 1 did not instruct Resident 19 to avoid chewing the medications. Resident 19 was observed making munching movements with their mouth. On 4/2/25 at 0825 hours, LVN 1 was observed administering one tablet of apixaban to Resident 19. However, LVN 1 did not assess or inquire whether Resident 19 exhibited any signs or symptoms of bleeding or bruising. b. Medical record review for Resident 29 was initiated on 4/1/25. Resident 29 was admitted to the facility on [DATE]. Review of Resident 29's Order Summary Report dated 4/2/25, showed the following physician orders: - dated 2/14/25, to monitor for signs/symptoms of anticoagulant complications: blood tinged or blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, severe bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. Report abnormal to physician and/or practitioner every shift. - dated 2/15/25: to administer apixaban 2.5 mg tablet by mouth twice daily for deep vein thrombosis prophylaxis. - dated 2/27/25: to administer metoprolol succinate (antihypertensive) 25 mg Extended Release tablet one-half tablet by mouth once daily for hypertension; and hold if SBP <105 mmHg or heart rate (HR) <60 bpm. Review of Resident 29's bubble pack of apixaban 2.5 mg tablets showed a label indicating the medication increases the risk of gastrointestinal bleeding and to report any bruising or bleeding to a physician. On 4/2/25 at 0900 hours, during an observation, LVN 1 administered one tablet of apixaban to Resident 29. However, LVN 1 did not assess whether Resident 29 had any signs or symptoms of bleeding or bruising. On 4/2/25 at 0910 hours, during an observation, LVN 1 administered one tablet of metoprolol 25 mg XL to Resident 29. However, LVN 1 did not instruct Resident 29 to avoid chewing the medication. On 4/2/25 at 0935 hours, during an interview, LVN 1 was asked about providing patient education regarding extended-release medications. LVN 1 stated the extended release medications should not be chewed and acknowledged not instructing Residents 19 and 29 to avoid chewing the medicine. LVN 1 verified he did not assess or asked questions for any signs or symptoms of bleeding or bruising to both of the residents before administering the apixaban medication. 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 22.58%. Two of two licensed nurses (LVNs 1 and 2) were observed to have made the errors during the medication administration. * LVN 2 failed to ensure the correct medications were administered to Resident 591 as per the physician's orders. * LVN 1 failed to ensure the education provided for not chewing the extended release medications for Residents 19 and 29. Additionally, LVN 1 failed to assess or ask Residents 19 and 29 if they had any signs or symptoms of bleeding or bruise. These failures had the potential to negatively affect the residents' health conditions. Findings: 1. On 4/2/25 at 0809 hours, during the medication administration observation, LVN 2 administered the following medications to Resident 591 orally: - Metformin (antidiabetic)1000 mg one tablet - Oyster Calcium (supplement) 500 mg with Vitamin D 10 mcg one tablet - B complex with B12 (supplement) one tablet - DOK docusate sodium (stool softener) 100 mg one soft gel - multivitamins with minerals one tablet - acidophilus probiotic one tablet - LiquaCel concentrate liquid protein 16 grams/2.5 grams of arginine sugar free 30 ml - magnesium oxide (mineral) 400 mg - MiraLAX polyethylene glycol (laxative) 3350 - Multi Vitamins one tablet - GeriKot (stool softener) 8.6 mg one tablet - Zinc (mineral) 50 mg one capsule - Vitamin C 500 mg one tablet Medical record review was initiated on 4/2/25 on Resident 591. Resident 591 was admitted on [DATE]. Review of Resident 591's H&P examination dated 3/24/25, showed a list of medications including the following medications: - Emergen-C Blue oral packet (multiple vitamins with minerals) one packet by mouth one time a day for supplement - Caltrate 600 + D3 (vitamin) oral tablet 600-20 mg-mcg one tablet by mouth two times a day for supplement Review of Resident 591's Order Summary Report dated 4/2/25, showed the following medications were scheduled for 0900 hours: - cyanocobalamin tablet (vitamin) 1000 mcg one tablet by mouth one time a day - Emergen C- Blue oral packet (multivitamins with minerals) one packet by mouth one time a day - lactobacillus (probiotic) oral tablet one tablet by mouth one time a day - LiquaCel oral liquid (amino acids) 30 ml by mouth one time a day - magnesium oxide oral tablet 400 mg one tablet one time a day - MiraLax powder 17 gm/scoop (polyethylene glycol 3350) one scoop by mouth as needed, to mix with six to eight ounces of fluids. - multivitamin adult oral tablet (multiple vitamin) one tablet by mouth one time a day - Senna Lax oral tablet 8.6 mg one tablet by mouth one time a day - vitamin C oral tablet 500 mg (ascorbic acid) one tablet by mouth one time a day - zinc sulfate capsule 220 mg one capsule by mouth one time a day - Caltrate 600 + D3 (calcium carbonate - cholecalciferol) oral tablet 600-20 mg-mcg one tablet by mouth two times a day - docusate sodium oral tablet 100 mg one tablet by mouth two times a day - metformin HCl oral tablet 1000 mg two times a day On 4/2/25 at 1207 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 591 received multivitamin with minerals in a tablet form instead of packet form as per the physician's order. LVN 2 stated they ran out of multivitamin with minerals in the paket form. LVN 2 further verified the wrong dosage of oyster calcium was given to the resident. LVN 2 acknowledged and verified the above findings. On 4/2/25 at 1217 hours, an interview was conducted with the Central Supply staff. The Central Supply staff stated when the stock was low for the OTC (over the counter) medications, the nurses would write down what OTC medications were needed and the Central Supply staff would reorder. The Central Supply staff further stated if the medication delivery was delayed, the Central Supply staff would go to a local pharmacy to purchase as instructed by the DON. On 4/2/25 at 1445 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 reviewed the above medication errors and verified the findings. RN 1 stated from the time of resident admission, the clarification should have been done with the physician's orders. On 4/7/25 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON verified the above findings.

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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2. On 4/2/25 at 1402 hours, Medication Cart 1 was observed parked in the hallway facing the entrance lobby near the nurses' station. The nurses at the nurses' station were observed using the computer, and not attending to Medication Cart 1. Medication Cart 1 was observed unlocked and unattended. The residents, visitors, and staff were observed passing by the medication cart. On 4/2/25 at 1404 hours, an observation of Medication Cart 1 and concurrent interview was conducted with LVN 1. Medication Cart 1 was observed unlocked and unattended. LVN 1 verified the above findings. LVN 1 stated he forgot to lock Medication Cart 1 because he had to check a resident. LVN 1 stated Medication Cart 1 should be locked at all times. Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in a safe and secure manner. * The facility failed to the medications were properly stored in the location where they could not be accessible by the non-licensed staff. * The facility failed to ensure Medication Cart 1 was locked when not in use. These failures had the potential for unauthorized persons to have access to locked medications. Findings: Review of the facility's P&P titled Storage of Medications, revised 11/2020 showed the facility stores all the drugs and biologicals in a safe, secure and orderly manner. The drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only the person authorized to prepare and administer medications have access to locked medications. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators , carts and boxes) containing drugs and biologicals are locked when not in use. 1. On 4/02/25 at 1355 hours, an interview and concurrent observation of the central supply room was conducted with the DON and CNA 4. CNA 4 stated he was the central supply room designee and had the key to the central supply room. An open metal shelf was observed with the following medications: - six bottles of Thera Antifungal Body Powder, - two boxes of Hydrocortisone Cream 1% tube Itch Relief, - four boxes of Zinc Oxide ointment Skin Protectant tubes, and - one box of sachet containing Triple antibiotic Ointments. CNA 4 was asked how these medications were dispensed to the nurses. CNA 4 stated he gave the medications to the nurses when they asked for it. The DON verified the findings and stated these medications should not be in the central supply room where non-licensed staff could access it. The DON further stated the medications should have been placed inside an enclosed locked cabinet that only the licensed nurses could access.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Review of the facility's P&P titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcome revised December 2016 showed the IP or designee will review the antibiotic utilization as a part of the antibiotic stewardship program and identify the specific situations that are not consistent with the appropriate use of antibiotic. The P&P further showed at the conclusion of the review, the provider to be notified of the review findings. Review of the facility's document titled Infection Surveillance Monthly Report for February 2025 showed Residents 29, 640, and 641 were prescribed with the antibiotics in February but did not meet the McGeer's Criteria. Further review of the Infection Surveillance Monthly Report for February 2025 showed the column for Comments with the following information: - for Resident 29, per MD continue IV antibiotic, - for Resident 640, per MD complete antibiotic course, and - for Resident 641, MD notified still wants to complete course. Review of Residents 29, 640, and 641's medical records failed to show the name of the physician, date, and time when the physician was notifed; and name of the nurse who notified the physican and received the order and the justification or reason to continue the anitbiotic medication use when the residents did not meet the McGeer's Criteria. On 4/3/25 at 1323 hours, an interview and concurrent medical record review was conducted with the IP. When asked when and who notified the physician, the IP was unable to locate the documentation in the Infection Surveillance Monthly Report or in Residents 29, 640, or 641's medical record to show the name of the physician, date and time when the physician was notified, and name of the nurse who notified the physican and received the order and justification to continue the antibiotic treatments for the residents who did not meet the McGeer's Criteria. 4. Medical record review for Resident 28 was initiated on 4/3/25. Resident 28 was admitted on [DATE]. a. Review of Resident 28's Skilled Nursing - Psychotropic Consent dated 2/24/25, for the use of the lorazepam medication every 12 hours showed the provider's signature. However, the form failed to show the date when the provider had signed the consent for the lorazepam medication. Review of Resident 28's H&P examination dated 2/26/25 showed Resident 28 has the capacity to understand and make decisions. The H&P further showed Resident 28 was on the lorazepam 1 mg tablet, give one tablet by mouth two times daily for14 days. On 4/7/25 at 900 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified and acknowledged the consents for Resident 28 were incomplete. RN 1 stated, this is not good, all consents should have been completed. b. Review of the facility's P&P titled Administering Medications revision date April 2019 showed the individual administering the medication, initials the resident's MAR on the appropriate line after giving each medication, before administering the next one. Review of Resident 28's MAR for March 2025 showed a blank documentation during the morning shift on 3/5/25, for the following medications, treatments, and monitoring: - the covid 19 monitoring; - the documentation for the number of times of the urine output; - the enhanced barrier precaution; - the lactobacillus oral capsule (a probiotic medication); - the lactulose oral solution (bowel management) medication; - the resident ' s intake in ml provided by nursing during each shift; - the observation for the central venous catheter site for signs and symptoms of infiltration /extravasation, redness, swelling or pain every shift; - the monitoring for the presence of pain every shift; - the pain non-pharmacological intervention provided every shift; - the snacks being provided three times a day; - the Voltaren (arthritis pain relief) external gel 1%, applied to left and right shoulder topically three times daily; - the respiratory order for incentive spirometer four times a day; and - the vancomycin HCL oral suspension (antibiotics) 50 mg/ml by mouth four times a day. Review of Resident 28's MAR for April 2025 showed a missing or inaccurate documentation for the monitoring for the signs/symptoms of the anticoagulant (blood thinner medication) complications during the day and night shift on 4/1/25. The MAR showed documentation 60 for the section to document if the resident with signs and symptoms from the use of the anticoagulant complications. On 4/7/25 at 0908 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 was asked regarding Resident 28's inaccurate documentation of the monitoring for the signs/symptoms of the anti-coagulant complications during the night shift on 4/1/25. RN 1 stated, I don't know why it was document as 60, it should have been a positive or negative sign. On 4/7/25 at 1502 hours, an interview and concurrent medical review was conducted with LVN 4. LVN 4 stated, yes, I remember I gave the medications and did all of the treatment left and may have forgotten to click them (to save) after I did. LVN 4 further stated I should have clicked saved after I administered the medications and monitored Resident 28, then rechecked for the completion at the end of the shift. 5. Medical record review for Resident 25 was initiated on 4/4/25. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Skilled Nursing- Psychotropic Consent dated 3/13/25, failed to show the physician's signature and date. Review of Resident 25's Physician's Progress Note dated 3/31/25, showed Resident 25's mental status was alert, interactive, and cooperative. Review of Resident 25's Order Summary Report dated 4/2/25, showed a physician's order dated 3/31/24, for bupropion HCl (medication to treat depression) tablet extended release 150 mg one tablet by mouth one time a day for depression. On 4/4/25 at 1359 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated she would follow up any incomplete consents after a resident's admission. LVN 4 stated she would check the physician's progress notes if the resident or family was notified of the medication, consented or declined to give the consent. LVN 4 further stated if there was no documentation, she would follow up with the physician and the resident's family member then would complete the consent form. LVN 4 verified and acknowledged Resident 25's informed consent for the buspirone medication was incomplete. On 4/7/25 at 0900 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified and acknowledged the consent for Residents 25 was incomplete. RN 1 stated, this is not good, all consents should have been completed. On 4/7/25 at 1330 hours, an interview was conducted with the DON and Administrator for Residents 25, 26, and 28. The DON and Administrator were made aware and acknowledged the above findings. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' medical records were complete and accurate for six of 13 final sampled residents (Residents 16, 17, 25, 28, 29, and 339) and two nonsampled residents (Residents 640 and 641). * The facility failed to ensure the signatures on the informed consent for the buspirone (antianxiety medication) medication for Resident 16 matched the printed names on the consent form. Additionally, Resident 16's MAR entries failed to show the job designation of the staff signing. * The facility failed to ensure the MAR entries showed the job designation of the staff signing the MAR for Residents 17, and 339. * The facility failed to ensure Resident 28's medication administrations, treatments, and monitorings were documented in the MAR after it was administered or provided. Additionally, the consent to treat and consent for the use lorazepam (antianxiety medication) was incomplete. * The facility failed to ensure Resident 25's consent for the use of the buspar medication (antianxiety) was complete. * Resident 2's advance directive was not available in active medical record. * The facility failed to document the physician's name, date and time when the physician was notified and name of the nurse who notified the physician when Residents 29, 640, and 641 did not meet the McGeer's criteria but received the antibiotic treatments. These failures posed the risk for the resident care needs not being met as their medical record information were inaccurate and incomplete. Findings: Review of the Health and Human Services Agency, California Department of Public Health AFL (All Facilities Letter) 24-07 showed under the examination and signatures: before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain the informed written consent signed by the resident or the resident's representative along with, the signature of the health care professional declaring the required material information has been provided. If the resident or resident's representative cannot sign the form, a licensed nurse can sign the form and document the name of the person who gave consent and the date. 1. Medical record review for Resident 16 was initiated on 4/1/25. Resident 16 was readmitted to the facility on [DATE]. * Review of Resident 16's Order Summary Report showed a physician's order dated 3/18/25, to administer buspirone 5 mg one tablet two times a day, to start on 3/25/25. Review of Resident 16's Skilled Nursing - Psychotropic Consent - V1 dated 3/24/25, showed a verbal consent was obtained from Resident 16. The consent form, under the Verbal Consent section, showed the names of RN 1 and the DON printed as the healthcare professional/ facility staff. Further review of the consent form did not show the signatures of RN 1 and the DON, and there was no signature of the physician. On 4/3/25 at 1337 hours, an interview and medical record review was conducted with the Medical Records Director. The Medical Records Director stated the informed consent forms were kept in an accordion file folder in her office, and the informed consent forms and all other medical records were uploaded to the resident's electronic health records as soon as the physician had signed it, and all the information on the medical record forms was completed. When asked about Resident 16's informed consents, the Medical Records Director stated, everything has been uploaded to PCC. On 4/3/25 at 1350 hours, an interview and medical record review was conducted with the DON. When asked about Resident 16's informed consent for buspirone medication, the DON verified the form in the resident's electronic health record did not show the signatures of RN 1 and the DON. On 4/3/25 at 1520 hours, the Medical Records Director gave a copy of Resident 16's Skilled Nursing - Psychotropic Consent - V1 dated 3/24/25, for the buspirone medication. The consent form showed the names of RN 1 and the DON printed as the healthcare professional/ facility staff, with signatures below their printed name, and also a signature of the physician. On 4/4/25 at 1045 hours, a follow-up interview and concurrent medical record review was conducted with the DON. Review of Resident 16's Skilled Nursing - Psychotropic Consent - V1 dated 3/24/25, for buspirone medication showed the names of RN 1 and the DON printed as the healthcare professional/ facility staff, with signatures below their printed name, and a signature of the physician. When asked about the signatures on the consent form, the DON stated the MDS Coordinator and another LVN signed the consent form. The DON acknowledged the signatures were not signed by the healthcare professional/ facility staff who actually verified the resident's informed consent for the buspirone medication. On 4/4/25 at 1100 hours, an interview and medical record review was conducted with the MDS Coordinator. When asked about the residents' informed consent. The MDS Coordinator stated the informed consents for psychotropic medications were obtained by the nurses, and if missed, she would follow up with the resident. When asked about the informed consent for buspirone medication for Resident 16, the MDS Coordinator stated RN 1 and the DON already spoke to the resident about the buspirone medication, and she did not speak to Resident 16 about the buspirone medication, but she acknowledged she signed the consent form. On 4/4/25 at 1110 hours, an interview and medical record review was conducted with LVN 1. When asked about the informed consent for buspirone medication for Resident 16, LVN 1 stated he did not speak with Resident 16 about the buspirone medication, but he acknowledged he signed the consent form. * Review of Resident 16's MAR for March 2025, under the Staff Administration Legend section, did not show the professional titles for seven of 10 staff who signed the MAR. Review of Patient 16's MAR for April 2025, under the Staff Administration Legend section, did not show the professional titles for two of four staff who signed the MAR. On 4/7/25 at 1027 hours, an interview and concurrent medical record review for Patient 16 was conducted with the DON. The DON verified the above findings. 2. Medical record review for Resident 17 was initiated on 4/1/25. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's MAR for March 2025, under the Staff Administration Legend section, did not show the professional titles for 12 of 14 staff who signed the MAR. Review of Patient 17's MAR for April 2025, under the Staff Administration Legend section, did not show the professional titles for four out of four staff who signed the MAR. On 4/7/25 at 1027 hours, an interview and concurrent medical record review for Patient 16 was conducted with the DON. The DON verified the above findings. 3. Medical record review for Resident 339 was initiated on 4/1/25. Resident 339 was readmitted to the facility on [DATE]. Review of Resident 339's MAR for March 2025, under the Staff Administration Legend section, did not show the professional titles for one of two staff who signed the MAR. Review of Patient 339's MAR for April 2025, under the Staff Administration Legend section, did not show the professional titles for three of three staff who signed the MAR. On 4/7/25 at 1027 hours, an interview and concurrent medical record review for Patient 16 was conducted with the DON. The DON verified the above findings. 6. Medical Record review for Resident 2 was initiated on 4/1/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 3/18/25, showed Resident 2 had the capacity to understand and make decision. Review of Resident 2's POLST dated 3/17/25, under section D for the advance directive, showed no documented evidence whether the advance directive had been discussed, if unavailable, or not applicable. On 4/2/25 at 1450 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD was asked whether Resident 2 had been offered an advance directive and to provide documentation of it. The SSD stated Resident 2 had the capacity but was unable to provide documentation of the resident's advance directive. The SSD further stated upon admission, the admission coordinator should have uploaded the advance directive to Resident 2's medical record. The SSD verified the above findings.

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** Based on interview, facility document review, and facility P&P review, the facility failed to ensure the infection control practices were maintained. * The facility failed to accurately classify which residents met the McGeer's Criteria in the infection control surveillance. This failure posed the risk of inaccurately identifying if the residents met the criteria for true infections and appropriate antibiotic use. * The facility failed to implement the neutropenic precautions for Resident 17. Fresh flowers were observed at bedside, the door was not kept closed, and the IP was observed entering the room without a mask. * The facility failed to ensure the enhanced barrier precautions for Resident 591 were observed. * The sink in Medication Room A was not clean. These failures posed the risk of potential transmission of communicable diseases to other residents in the facility. Findings: 1. According to the CDC, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria. Review of the facility's P&P titled Antibiotic Stewardship-Order for Antibiotics dated 12/2016 showed the appropriate use of antibiotic included criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending). Review of the facility's P&P titled Antibiotic Stewardship-Review and Surveillance of Antibiotic Use and Outcome revised 12/2016 showed the IP or designee will review antibiotic utilization as a part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotic. The P&P further showed at the conclusion of the review, the provider to be notified of the review findings. On 4/7/25 at 1019 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated the Infection Surveillance Monthly Reports were the tool the facility to use to track the infections. Review of the December 2024 and January 2025 Infection Surveillance Monthly Reports failed to show the tracking for the residents who did not meet the McGeer's Criteria. The IP verified the above information and was unable to provide alternate documentation to show for the tracking of the resident's McGeer's criteria. 3. On 4/7/25 at 832 hours, Resident 591 was observed being transferred by CNA 2 from the bed to the wheelchair inside her room. CNA 2 was observed not wearing a gown during the transfer. A signage was observed outside Resident 591's room for the Enhanced Barrier Precautions and the instructions included the donning of the PPE. On 4/7/25 at 0837 hours, interview was conducted with CNA 2. When asked what PPE to use during the care of Resident 591, CNA 2 stated, I wear a gown and gloves when I am changing her and not during transfers. CNA 2 was shown the signage outside the room regarding the Enhanced Barrier Precautions which included dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting care, device care or use including urinary catheter and wound care. Medical record review for Resident 591 was initiated on 4/7/25. Resident 591 was admitted to the facility on [DATE]. Review of Resident 591's Order Summary Report showed a physician's order dated 3/22/25, for the Enhanced Barrier Precautions secondary to the presence of the indwelling medical device. On 4/7/25 at 0844 hours, an interview was conducted with LVN 2. LVN 2 was asked regarding Resident 591's enhanced barrier precaution order. LVN 2 stated, we have to wear a PPE when taking care of Resident 591. LVN 2 was made aware that CNA 2 did not wear a gown during Resident 591's transfer from the bed to the wheelchair. LVN 2 stated CNA 2 should have worn a gown. On 4/7/25 at 1315 hours, an interview was conducted with the IP. The IP stated a gown must be worn when taking care of a resident on an enhanced barrier precautions including the transfers. The IP acknowledged the above findings. On 4/7/25 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was made aware and acknowledged the above findings. 4. Review of the facility's P&P titled Storage of Medications revised 11/2020 showed the facility stores all the drugs and biologicals in a safe, secure, and orderly manner. The nursing staff is responsible for maintaining the medication storage and preparation areas in a clean, safe and sanitary manner. On 4/2/25 at 0910 hours, an interview and concurrent observation of Medication Room A was conducted with RN 1. RN 1 verified the sink in Medication Room A was dirty, the sink strainer had brown color discoloration, the circular portion surrounding the drainage had bluish discoloration measuring approximately 5 cm x 7 cm in its widest diameter, and the elongated dirt materials were soaked in water at the base of the strainer. There was also whitish streak discoloration at the top of the sink on the right side of the faucet. RN 1 stated the water was leaking from the faucet and sink was stained blue. RN 1 verified the sink needed maintenance and needed to be cleaned. On 4/2/25 at 0920 hours, an interview and concurrent observation of Medication Room A's sink was conducted with the DON. The DON verified the findings and stated it should be clean all the time. 2. Review of the facility's P&P titled Isolation - Categories of Transmission-Based Precautions revised 9/2022, under the Neutropenic Precautions (Reverse Isolations) section, showed the following: - Neutropenic precautions, also known as reverse isolation, are implemented to protect immunocompromised residents from potential sources of infection. These residents are at increased risk for acquiring infections from other individuals or the environment due to weakened immune systems; - The resident is placed in a private room with strict attention to cleanliness and infection control practices; - Masks may be worn by staff and visitors, especially if there is a known risk of respiratory infection; and - Fresh flowers, plants, and fruits/vegetables that are not fully cooked or washed are typically restricted due to potential sources of pathogen. Review of the facility's document titled Neutropenic Precautions showed the following: - For the visitors to report to the nurses' station before entering the room; - Private room with closed door; - Handwashing is required upon entering the room; - No fresh fruits, vegetables or flowers maybe taken into the room; and - No visitors or staff with infections illnesses may enter the room. On 4/1/25 at 0935 hours, during the initial tour of the facility, a sign was observed outside Resident 17's room by the door, notifying the staff and visitors that the resident was on neutropenic precautions. A sign showing the sequence for putting on PPE was also posted outside Resident 17's room by the door. The door was observed open and Resident 17 was observed in bed. Two vases with fresh flowers were observed at bedside. Medical record review was initiated on 4/1/25. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Order Summary Report showed a physician's order dated 2/18/25, for neutropenic precautions related to cancer post chemo treatment. On 4/1/25 at 1130 and 1604 hours, on 4/2/25 at 0848 and 1406 hours, a neutropenic isolation sign was observed posted outside the resident's door. The door was observed open. On 4/2/25 at 1409 hours, an observation for Resident 17 and concurrent interview was conducted with the IP. A neutropenic isolation sign was observed posted outside the resident's door. The door was observed open. Resident 17 was observed in bed and asked for assistance with repositioning her arm. Two vases with fresh flowers were observed at bedside. The IP was observed going into the room with gown and gloves but without a mask on. The IP was observed assisting Resident 17. The IP verified she did not wear a mask when she entered the room and had assisted Resident 17. The IP also verified the door was open, and there were two vases with fresh flowers at the resident's bedside. The IP stated the mask, gloves, and gown should be worn when entering the room on neutropenic precaution and the door should be closed at all times.

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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2. According to the FDA Food Code 2022 Section 4-501.11 showed equipment shall be maintained in good repair and proper adjustment. Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Review of the facility's P&P titled Ice Machines and Ice Storage Chests revised 1/2012 showed the facility has established procedures for cleaning and disinfecting ice machines and ice storage chests which adhere to the manufacturer's instructions. Review of the Manitowoc Indigo NXT Ice Machines Installation, Operation and Maintenance Manual dated 5/11/18, under Maintenance section showed the following: - Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment. An extremely dirty ice machine must be taken apart for cleaning and sanitizing; - Manitowoc Ice Machine Cleaner and Sanitizer are the only products approved for use in Manitowoc ice machines; - For exterior cleaning, clean the aera around the ice machine as often as necessary to maintain cleanliness and efficient operation. Wipe surface with a damp cloth rinsed in water to remove dust and dirt from the outside of the ice machine. If a greasy residue persists, use a damp cloth rinsed in a mild dish soap and water solution, and wipe dry with a clean, soft cloth; and - The cleaning and sanitizing procedure must be performed a minimum of once every six months. The ice machine and bin must be disassembled, cleaned and sanitized. Review of the facility's document titled Invoice from the facility's outside vendor showed a preventative maintenance cleaning and sanitizing was performed on the ice machine in the main kitchen on 2/20/25. Review of the facility's document titled Ice Machine Cleaning Log showed the ice machine in the main kitchen was cleaned on 3/8/25. On 4/2/25 at 0942 hours, an inspection of the ice machine in the main kitchen, interview and concurrent facility document review was conducted with the Director of Maintenance. The ice machine was observed with black particles on the ice machine deflector and on the groove in front of deflector when wiped with a white paper towel. The Director of Maintenance verified the above findings. The Director of Maintenance stated an outside vendor provided cleaning service to the ice machine quarterly. The Director of Maintenance also stated the dietary staff was responsible for cleaning the exterior of the ice machine, and the bin of the ice machine. The Director of Maintenance stated the dietary staff used a food-grade multi-quat sanitizing solution to clean the bin of the ice machine. The Director of Maintenance verified the dietary staff was not using the Manitowoc Ice Machine Cleaner and Sanitizer solution as indicated in the manufacturer's manual to clean the ice storage bin of the ice machine in the main kitchen nor the exterior of the ice machine. Cross-reference to F812, example #3.a. 3. a. On 4/1/25 at 0850 hours, an observation of the main kitchen and concurrent interview was conducted with the Culinary Director. There was no thermometer observed inside the walk-in freezer. The walk-in freezer was observed with a thick ice build-up from floor to the ceiling on the interior part of the freezer near the door. There were several food items in the freezer that were covered with ice. The Culinary Director verified the above findings. The Culinary Director stated there was something wrong with the freezer door and a new freezer door had been ordered. On 4/3/25 at 0949 hours, an interview and concurrent facility document review was conducted with the Director of Maintenance. The Director of Maintenance stated there was an ice build-up because the needed to be replaced and stated a there was a lead time of four to six weeks when the freezer door will be delivered. When asked when the freezer door was inspected and the walk-in freezer cleaned, the Director of Maintenance stated they removed the ice build-up and cleaned the walk in area a couple of days ago. Review of the facility's document titled Freezer Door Cleaning Log showed it was signed off on 3/3, 3/10, 3/17, 3/24, and 3/31/25. b. On 4/1/25 at 0821 hours, during the initial tour of the satellite kitchen, ice build-up was observed inside the freezer. The Dietary Aide verified the above findings. c. On 4/1/25 at 1133 hours, an inspection of the refrigerator used for the residents' food brought from outside and concurrent interview was conducted with RN 1. An ice-build up was observed inside the freezer and a brownish discoloration was observed on the shelves of the refrigerator used for the residents' food brought from the outside source. RN 1 verified the above findings. On 4/3/25 at 0949 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance stated the housekeeping staff was responsible for the weekly cleaning of the refrigerator used for the residents' food brought from the outside sources, which was usually on Mondays. On 4/3/25 at 1016 hours, an interview was conducted with the CDM. The CDM stated the dietary staff was responsible for the weekly cleaning of the refrigerator used for residents' food brought from outside sources. 4. According to the FDA Food Code 2022, section 4-502.11, showed food temperature measuring devices shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy. Review of the Lonicera Thermometer User Instruction (undated) showed to calibrate, take a cup of water and insert the probe into the ice water to touch the ice. When the final temperature is reached, hold down the CAL button for five seconds. After five seconds, the display will flash CAL on the screen, then the digit will flash, then press the C/F button to increase the digit or the HOLD button to decrease the digit until 0C or 32 F is reached. Review of the facility's P&P titled How to Calibrate Thermometers: Bi-Metallic Stem and Digital revised 12/12/19, showed calibration of thermometers is a must in order to assure the temperature displayed on the thermometer is accurate. The method of calibration for bi-metallic stem and digital thermometers includes the following: - Fill a medium size glass with clean ice; - Add ½ cup clean water to the ice and wait for two minutes; - Using the case as a handle, place the thermometers in the middle of the ice water and wait for three minutes while stirring the water occasionally. The thermometer must be two inches deep in the water and ice in order for the sensing area to be covered completely; - If the temperature reading is 32 degrees F, the thermometer is calibrated accurately. If the thermometer does not record 32 degrees F, then an adjustment Is needed. For digital thermometer, leave it in ice water. Press the reset button. If it does not read 32 degrees F, add a battery and recheck or replace the thermometer. On 4/2/25 at 1117 hours, a thermometer calibration observation and concurrent interview was conducted with the Dietary Aide, and the CDM was present. The Lonicera thermometer was observed in a cup with ice and water. The Dietary Aide stated to calibrate the thermometer, the C/F button needed to be pressed and then wait for the temperature to go down to 32 degrees F. The Dietary Aide was observed pressing the C/F button. Then, the Dietary Aide was observed repeatedly pressing the C/F and HOLD buttons. The thermometer showed 33.4 degrees F temperature. The Dietary Aide was observed using the thermometer to check the food temperature. The CDM verified the above findings. On 4/3/25 at 1016 hours, an interview was conducted with the CDM and RD. The CDM verified the Dietary Aide did not calibrate the thermometer correctly. The CDM stated the Dietary Aide was supposed to push the calibrate button for five seconds, and let the thermometer sit in the cup with water and ice, then lift the thermometer up and pushed the button more to get the temperature down to 32 degrees F. Based on observation, interview and facility P&P review, the facility failed to ensure the equipment was maintained in a safe and operable manner. * The sink faucet in Medication Room A was leaking. * The facility failed to ensure the ice machine in the main kitchen was cleaned and sanitized as per the manufacturer's specifications. * The facility failed to ensure there was no ice build-up in the walk-in freezer in the main kitchen, the freezer in the satellite kitchen, and the freezer of the refrigerator used for residents' food brought from outside source. * The facility failed to ensure the thermometer used in the satellite kitchen was calibrated properly. These failures had the potential for the equipment to not function in the way it was intended. Findings: 1. Review of the facility's P&P titled Maintenance Service revised 12/2009 showed the maintenance department is responsible for maintaining the buildings, grounds and equipment in a safe and operable manner at all times. Maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds and equipment are maintained in a safe and operable manner. On 4/2/25 at 0910 hours, an interview and concurrent observation of Medication Room A was conducted with RN 1. RN 1 verified the sink faucet in Medication Room A was leaking, the sink strainer had brown color discoloration, the circular portion surrounding the drainage had bluish discoloration measuring approximately 5 cm x 7 cm in the widest diameter, and the base of the strainer was soaked with water. RN 1 verified water was leaking from the faucet and the sink was stained blue. RN 1 stated maintenance should have fixed the leakage, and nurses should have reported when they found the leakage. On 4/2/25 at 0920 hours, an interview and concurrent observation of Medication Room A sink was conducted with the DON. The DON verified the leaking faucet from the sink. The DON stated they would discuss with the Administrator and maintenance staff to fix it. On 4/2/25 at 1005 hours, an interview was conducted with the Director of Maintenance. The Director of Maintenance verified the leaking faucet and stated it could have been fixed if the nurses had reported the leakage.

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** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' beds were inspected and the entrapment assessments were conducted when identifying areas of possible entrapment with the use of bed rails for two of four final sampled residents (Residents 26 and 339) investigated related to the use of side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: 1. 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 frame, mattress, side rails, headboard, footboard, and bed accessories, the facility shall promote the following approaches: - Inspection by the maintenance staff of al 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. The review shall consider situations that could be caused by the resident's weight, movement or bed position; and - Identify additional safety measures for residents who have been identified as higher than usual risk for injury including entrapment such as altered mental status, restlessness, etc. On 4/1/25 at 0904 hours, 4/3/25 at 1412 hours, 4/4/25 at 1030 hours, and 4/7/25 at 0942 hours, Resident 339 was observed lying in bed with the bilateral grab rails elevated. Medical record review for Resident 339 was initiated on 4/1/25. Resident 339 was admitted to the facility on [DATE]. Review of Resident 339's Order Summary Report showed a physician's order dated 3/31/25, for the bilateral deluxe assist bed handles while in bed for turning and positioning. Review of Resident 339's Skilled Nursing - admission Initial Eval - V 13 dated 3/31/25, showed the following: - The Cognition/ Mental Status section showed Resident 339 was alert and oriented; - The Functional GG section showed Resident 339 required supervision from the facility staff for mobility and transfers; and - The Side/ Bed Rail Evaluation, Evaluation of Entrapment Risk section showed there were gaps between the resident's mattress and side/ bed rail, headboard and footboard. On 4/7/25 at 1027 hours, an interview and concurrent medical record for Resident 339 was conducted with the DON. The DON verified the initial evaluation for Resident 17 showed there were gaps between the resident's mattress and side/bed rail, headboard, and footboard. On 1/24/25 at 1225 hours, a concurrent interview and facility document review for Resident 339 was conducted with the Director of Maintenance. The Director of Maintenance stated the maintenance department was responsible for the yearly bed inspection of all the beds in the facility, including the Entrapments Zones 1 to 4. When asked if he inspected the bed when there was a change of bed or mattress or a new resident to determine if any areas of possible entrapment are present based on the change of the bed, or mattress, or user, the Director of Maintenance stated he did not go back to check, not unless the resident had a low air loss mattress. The Director of Maintenance also stated they would only check the bed frame when the nurses reported to have it repaired. When asked to show documentation of his bed inspection, the Director of Maintenance showed and verified the following documents: - The facility document titled Bed Safety Action Grid dated 6/1/18, showed Entrapment Zones 1 to 4 were encircled. - The facility document titled Bed Rail Inspection dated 1/25/25, showed Resident 339's bed passed. - The facility document titled Entrapment Measurements for Resident 339's bed dated 1/25/25, showed Zones 1 to 4 were marked P. The areas to show entrapment measurements between the mattress and the headboard and footboard were left blank. The Director of Maintenance verified the above findings. When asked if the nurses reported the initial evaluation on 3/31/25, for Resident 17 showing there were gaps between the resident's mattress and side/bed rail, headboard, and footboard and if he conducted a bed inspection and entrapment assessment for Resident 17, the Director of Maintenance answered no. The Director of Maintenance stated he only conducted the bed inspection with the entrapment assessments on 1/25/25, for all the beds in the facility. 2. On 4/1/25 at 1048 hours, during the initial tour of the facility, Resident 26's bed was observed to have the bilateral enablers. Medical record review for Resident 26 was conducted on 4/7/25. Resident 26 was admitted to the facility on [DATE]. Reviewed Resident 26's Order Summary Report dated 4/7/25, showed a physican's order dated 3/3/25, for deluxe assist bed handles up times two while in bed for turning and positioning. Review of Resident 26's Skilled Nursing - admission Initial Evaluation dated 3/3/25, the section for Side/Bed Rail Evaluation - Evaluation of Entrapment Risk, showed, yes to all the questions if the side rails had gaps between mattress, and side/bed rail, headboard or footboard. On 4/7/25 at 1307 hours, a concurrent observation, interview and facility document review was conducted with the Director of Maintenance. The Director of Maintenance stated the side rails were being inspected annually and as needed when a low air pressure mattress was used. When asked for the bed entrapment measurement documentation for Resident 26, the Director of Maintenance stated he performed the assessment on all the beds on 1/25/25. However, the Director of Maintenance was unable to provide the documentation of the bed entrapment measurements for Resident 26. Resident 26's Evaluation of Entrapment Risk dated 3/3/25, was reviewed with the Director of Maintenance. The Director of Maintenance stated he was not aware of any reported gaps between the mattress, and side/bed rail, headboard or footboard. On 4/7/25 at 1330 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was made aware 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, 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 proper labeling and dating of the food items and expired food items were discarded in the satellite kitchen. * The facility failed to ensure the proper labeling and dating of the foods in the refrigerator was in place for the residents' food brought in by the visitors. * The facility failed to ensure the bins, scoops, spoons, peeler, can opener, and microwave were clean. * The facility failed to air dry the scoops before storing in the storage bin. * The facility failed to ensure the cutting boards were kept in a sanitary condition. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's Diet Type Report dated 4/4/25, showed 42 of 43 residents residing in the facility received foods prepared in the kitchen. 1. Review of the facility's P&P titled Labeling and Dating for Safe Storage of Food revised 4/10/23, showed the following; - All products should be dated upon receipt; - All products should be dated when opened; - Use use-by dates on all food once opened and stored under refrigeration; and - When food is taken out of an original container, write the name of the food being stored on the container, the placed date, and the use-by date. On 4/1/25 at 0821 hours, an initial tour of the satellite kitchen and concurrent interview was conducted with the Dietary Aide. The following was observed: a. Two bags of cheese were not labeled and dated inside Refrigerator 1 b. The following was observed in Refrigerator 2: - A container of Thick and Easy water with lemon flavor was not labeled and dated; - A container of Thick and Easy water with apple flavor was not labeled and dated; - A container of Thick and Easy water with strawberry flavor was not labeled and dated; and - A container of Thirster prune juice was labeled with a use-by date of 3/27/25. c. An unlabeled container with brown granules was observed on the kitchen shelf. The Dietary Aide verified the above findings. The Dietary Aide stated the brown granules inside a container was coffee. The Dietary Aide stated the bags of cheese and container of thickened juices were just opened but she forgot to label the food items with the opened date. 2. Review of the facility's P&P titled Food from Outside Sources revised 1/22/19, showed if the food is brought in by visitors, friends, family members or resident's guests, the facility should help them understand safe food handling practices. On 4/1/25 at 1133 hours, an inspection of the refrigerator used for residents' food brought in from visitors, and concurrent interview was conducted with RN 1. A facility document (untitled) posted on the refrigerator door showed the following: - All food items brought in by family must be labeled with the name, date and room number; - If not labeled, it will be immediately discarded; and - Perishable foods will be tossed out after three days. The following food items were observed inside the refrigerator: - A small container of ice cream was not labeled with resident name, room and date received; - A container of wheat sprout spread was labeled with resident name, and dated 3/15/25; and - A container of dark chocolate mousse was labeled with resident name, but undated. RN 1 verified the above findings. RN 1 stated the food items were supposed to be labeled with the resident name, room number and date when the food items were received. RN 1 stated if the food item was from the restaurant and/or from home, the facility staff encouraged them to finish the food purchased from outside. When asked how long should the food from outside source be stored inside the refrigerator, RN 1 answered it should be 24 hours because they were not sure of how the food item was prepared and transported, and also because the refrigerator used to store food items from outside source was small. 3. According to the 2022 FDA Food Code, 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 2022 FDA Food Code, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. a. On 4/2/25 at 0942 hours, an inspection of the ice machine in the main kitchen and conducted interview and facility document review was conducted with the Director of Maintenance. The ice machine was observed with black particles on the ice machine deflector and on the groove in front of deflector when wiped with a white paper towel. The Director of Maintenance verified the above findings. The Director of Maintenance stated an outside vendor provided cleaning service to the ice machine quarterly. The Director of Maintenance also stated the dietary staff was responsible for cleaning the exterior of the ice machine, and the bin of the ice machine. The Director of Maintenance stated the dietary staff used a food-grade multi-quat sanitizing solution to clean the bin of the ice machine. Cross-reference to F908 #2. b. On 4/1/25 at 0821 hours, during the initial tour of the satellite kitchen and concurrent interview was conducted with the Dietary Aide. The following was observed: - A ice cream scoop was observed chipped and corroded; - A gray scoop was observed with food debris; - The can opener and peeler were observed with rust; - The white scoop, black serving spoon, and red adaptive spoon were observed with white stain; and - The storage bins for the scoops was observed with white stain. The Dietary Aide verified the findings. c. On 4/1/25 at 1044 hours, during the inspection of the main kitchen, five cupcake pans were observed with brownish discoloration. The Culinary Director verified the findings. d. On 4/2/25 at 0925 hours, the microwave used to warm the residents' food in the satellite kitchen was observed with a brownish discoloration and food debris. The CDM verified the findings. 4. According to the 2022 FDA Food Code, 4-901.11, Equipment and Utensils, Air- Drying Required, showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. On 4/1/25 at 0821 hours, during the initial tour of the satellite kitchen, six scoops were stored wet inside a storage bin. The Dietary Aide verified the findings. 5. According to the 2022 FDA Food Code, 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 4/1/25 at 0821 hours, a red cutting board was observed to be heavily marred with knife marks. The Dietary Aide verified the findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected multiple residents

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Based on observations, interview, and facility document review, the facility failed to ensure the most recent Recertification Survey's plan of correction was readily accessible to the residents and public. This failure posed the risk for the residents, their families, and visitors to not be aware of the facility's plan of correction for the last Recertification Survey as the documents were not available to review. Findings: On 4/2/25 at 1107 hours, during the residents' group meeting, five of nine residents stated they did not know where the latest survey results were located and were unaware of their rights to review the survey results. On 4/7/25 at 1000 hours, an interview and concurrent facility document review was conducted with the Administrator. A white binder containing the survey results was observed in the lobby area. The binder included the CMS 2567 from the last recertification survey conducted on 1/26/24. However, the binder did not contain the a copy of the Plan of Correction. The Administrator verified and acknowledged the findings and stated someone might have removed the Plan of Correction from the binder.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0813 (Tag F0813)

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 implement the P&P to ensure proper storage of food brought in by family members. * An unlabeled and undated bag of cereal was observed on Resident 29's bedside table. This failure had the potential to result in foodborne illnesses in a highly susceptible resident population. Findings: Review of the facility's P&P titled Foods Brought by Family or Visitors dated 3/2022 showed the food brought by family or visitors and left with the resident to consume later must be labeled and stored in a manner that clearly distinguishes it from facility-prepared food. Non-perishable foods must be stored in resealable containers with tightly fitting lids. Medical record review for Resident 29 was initiated on 4/1/25. Resident 29 was admitted to the facility on [DATE]. On 4/2/25 at 0900 hours, an observation and concurrent interview was conducted with LVN 1. There was an undated and unlabeled resealable, transparant plastic bag of dry cereal stored on Resident 29's bedside table. LVN 1 stated they only labeled the wet food, not dry food. On 4/2/25 at 1032 hours, an interview with the DON. The DON stated the bag of dry cereal should have been labeled and dated. The DON verified the findings.

Mar 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and facility P&P review, the facility failed to develop a plan of care to reflect the individual care needs for one of two sampled residents (Resident 1). * The facility failed to develop the care plan problem and interventions to address Resident 1's behavior of getting up from the wheelchair. This posed the risk of not providing appropriate, consistent, and individualized care to the resident. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 12/2016 showed for a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Medical record review for Resident 1 was initiated on 3/4/25. Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's admission Initial Evaluation dated 2/14/25, showed the resident was a fall risk and exhibiting the following behaviors: easily distracted, altered perception/awareness, disorganized thoughts, restlessness/lethargy and forgetfulness/confusion. Review of Resident 1's Change in Condition Evaluation dated 2/16/25, showed the resident was up in the wheelchair at the nursing station, and later the CNA found the resident sitting on the floor. Review of Resident 1's IDT Post Accident/Fall dated 2/17/25, failed to show the interventions to address Resident 1's behavior of getting up from the wheelchair and how to prevent the resident from further fall incidents. Review of Resident 1's MDS Section C – Cognitive Patterns dated 2/21/25, showed a BIMS score of 3, suggesting severe cognitive impairment. Review of Resident 1's Order Summary Report dated 2/21/25, showed to be up in the wheelchair two times a day with assistance. Further review of Resident 1's medical record failed to show the care plan problem and interventions were developed for Resident 1's behavior of getting up from the wheelchair and how to prevent the resident from further fall incidents. On 3/4/25 at 1120 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 1 had episodes of trying to get up from the wheelchair. On 3/24/25 at 1502 hours, an interview and concurrent medical review was conducted with the DON. The DON confirmed there was no care plan and its interventions were developed to address Resident 1's behavior of getting up from the wheelchair and how to prevent the resident from further fall incidents.

Jan 2024 30 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of 13 final sampled residents (Resident 330) was informed in advance of the proposed treatment regarding the use of psychotropic medications (medications affecting brain activity). * The facility failed to ensure the informed consent was obtained from Resident 330's responsible party before administering sertraline (antidepressant medication) to Resident 330. This failure had the potential to compromise the right of the resident or her responsible party (person designated to make decisions on behalf of the resident) to be fully informed regarding the medication and its potential side effects. Findings: Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's History and Physical examination dated 1/15/24, showed Resident 330 had no capacity to understand and make decisions. Review of the Order Summary Report showed a physician's order dated 1/16/24, to administer sertraline 50 mg one tablet a day for depression manifested by verbalization of sadness. Review of the Consent Form for Psychoactive Med Therapy dated 1/12/24, did not show the sertraline medication ordered. Review of the Informed Consent Form - Skilled Nursing (CA Only) dated 1/16/24, did not show the sertraline medication ordered. Further review of Resident 330's medical record did not show documented evidence of informed consent for the sertraline medication was obtained from Resident 330's responsible party. On 1/26/24 at 1008 hours, an interview and concurrent medical record review for Resident 330 was conducted with the DON. The DON verified the above findings. The DON verified the informed consent forms did not show the sertraline medication ordered for Resident 330. The DON acknowledged the informed consent forms were incomplete.

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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**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 reasonable accommodation to meet the needs of one of 13 final sampled residents (Resident 8). * The facility failed to ensure the call light for Residents 8 was within the resident's reach. This had the potential for the resident to not be able to call for assisstance when needed. Finding: Review of the facility's P&P titled Answering Call Light revised September 2022 showed the facility should ensure the call light is accessible to the resident when in bed, from the toilet, from the shower, from the shower or bathing facility & from the floor. During the initial tour of the facility on 1/23/24 at 1047 hours, Resident 8 was observed lying in her bed, awake, with the call light hanging on a metal rod on the right side of the head of bed. Medical record review for Resident 8 was initiated on 1/23/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's History and Physical examination dated 10/13/23, showed Resident 8 had no capacity to understand and make her own decisions. On 1/23/24 at 1055 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified Resident 8's call light was not within reach. CNA 1 stated Resident 8's call light should have been within the resident's reach. CNA 1 also stated the call light should always be within the reach of all the residents while they were in bed whether they were alert and oriented or confused. On 1/25/24 at 0855 hours, an interview was conducted with the DON. The DON stated the expectation was for the call light to be placed within reach of the residents even if the residents were confused. The DON stated their call light system was very sensitive also for the movements. If the resident was restless, constantly moving or trying to get out of bed, the call light helped to alert the staff to check on the resident. The DON was 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** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the residents' advance directives were part of their medical records for three of 13 final sampled residents (Residents 19, 25, and 429). This failure had the potential for the residents' wishes for provisions of health care not being followed. Findings: Review of the facility's P&P titled ADM- Advanced Directives dated 9/1/22, showed upon admission, the facility will ask the resident or the resident's representative if they have an Advance Directive, and copies are obtained and maintained in the residents' medical record. 1. Medical record review for Resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Further review of Resident 429's medical record failed to show a POLST and if the resident had an advance directive. Review of Resident 429's Generations Care Conference -V3 dated 1/17/23, the section for advance directive was incomplete. On 1/24/24, at 1009 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated they were the admitting nurse for Resident 429, and the LVN filled out a POLST for the resident. LVN 4 stated Resident 429's family member provided him a copy of the resident's advance directive on admission and they should both (POLST and advance directive) be in the binder at the station. Review of the binder labeled Facesheets, POLSTS, Inventory Records with LVN 4, LVN 4 verified Resident 429's POLST and advanced directive were not located in the binder. On 1/24/24, an interview was conducted with the SSD. The SSD stated Resident 429 informed her that he believed he had an advance directive and to ask Family Member 1. On 1/24/24 at 1132 hours, an interview was conducted with Family Member 1. Family Member 1 stated they provided a copy of Resident 429's advance directive to the nurse on admission, and the facility should have a copy of it. 2. Medical record review for Resident 19 was initiated on 1/23/24. Resident 19 was initially admitted to the facility on [DATE]. Review of the Resident - POLST dated 12/11/23, showed the resident did not have an advance directive. Review of Resident 19's admission MDS dated [DATE], showed the resident was cognitively intact. On 1/23/24 at 1211 hours, an interview was conducted with Resident 19. Resident 19 stated they had an advance directive and stated the facility was provided a copy of it. Review of Resident 19's medical record failed to show a copy of Resident 19's advance directive. Review of Resident 19's Generations Care Conference -V3 dated 12/10/23, showed the resident did not have an advance directive. Review of Resident 19's Physician Orders for Life-sustaining Treatment (POLST) dated 12/11/23, showed the resident did not have an advance directive. On 1/24/24 at 1012 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 reviewed Resident 19's POLST and stated it showed the resident did not have an advance directive. LVN 4 reviewed Resident 19's medical record and verified there was no advance directive. 3. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's History and Physical examination dated 12/29/23, showed Resident 25 did not have the capacity to understand, and make decisions. Review of Resident 25's Generations Care Conference dated 12/28/23, showed Resident 25 was admitted to the facility with an advanced directives. Review of Resident 25's POLST dated 12/28/23, under Section D-Information and Signatures, showed Resident 25 did not have an advance directive. Review of Resident 25's medical record failed to show documented evidence a copy of Resident 25's advance directive was obtained or a follow-up was made to obtain a copy of Resident 25's advance directive as per the facility's P&P. On 1/24/24 at 1445 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified the medical record did not contain a copy of Resident 25's advance directive. On 1/24/24 at 1615 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the above findings.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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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 timely notification of changes for one of 13 final sampled residents (Resident 16). * The facility failed to notify the physician, RD, and resident responsible party for the resident's weight changes. This failure had the potential for a delay of the interventions to prevent further weight loss/gain. Findings: Review of the facility's P&P Weight Assessment and Intervention dated 12/1/22, showed the following: - A weight change of 5% or more since prior weight assessment will be rechecked the next day, and if verified, nursing will immediately notify the dietitian. - Unless notified of a significant weight change (5% weight loss in a one month period; greater than 5% is severe weight loss.) Review of the facility's P&P Change in a Resident's Condition or Status revised 2/2021 showed the facility promptly notifies the resident's physician and responsible party of changes in the resident's medical status, including for significant changes in the resident's physical condition. The nurse will record the notification in the resident's medical record. Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's admission Record showed Resident 16's primary emergency contact was Family Member 2. Review of Resident 16's Weight and Vitals Summary in the resident's electronic medical record dated 1/24/24, showed the following weights: - 148.2 lbs, on 12/4/23, - 142.6 lbs, on 12/19/23, - 150 lbs, on 12/26/23 (5.2% and 7.4 lbs. increase from 12/19/24's weight), - 134.8 lbs, on 1/2/24 (10.1% and 15.2 lbs. decrease from 12/26/23's weight), and - 139.2 lbs, on 1/9/24. Review of Resident 16's Weight Record showed the following weights: -148.2 lbs, on 12/4/23, -142.6 lbs, on 12/19/23, -134.8 lbs, on 1/2/24, and -139.2 lbs, on 1/9/24, with written notes of weight gain dated 1/10/24, and positive edema (swelling caused by too much fluid trapped in the body's tissues) The weight record did not show the resident's weight obtained on 12/26/23. Review of Resident 16's Order Audit Report dated 1/26/24, showed on 1/4/24 at 2121 hours, a physician's order was obtained to refer to the RD for recent weight loss, 142.6 lbs on 12/19/23, and 134.8 on 1/2/24. The order was obtained two days after the most recent weight was obtained. On 1/25/24 at 1414 hours, an interview and concurrent record review were conducted with CNA 1. CNA 1 stated they weighted all the residents weekly and wrote it down on the Weekly Weights log, then recorded the weights in the resident's weight record and electronic medical record. CNA 1 stated they then gave the weight record to the resident's nurse if there were changes, so the nurse could do a change of condition. CNA 1 stated the nurse usually had their initials on the weight record to show they had reviewed it. When asked why Resident 16's weight on 12/26/23, was not recorded on their weekly weight record, CNA 1 stated they must have forgotten. Review of Resident 16's eINTERACT Change in Condition Evaluation - V 5.1 dated 1/3/24, showed an incomplete assessment for a weight loss. The sections for reviewing the findings with the physician showed the physician's recommendation and responsible party notification sections were blank. Review of Resident 16's progress notes failed to show the physician was notified of Resident 16's weight gain on 12/26/23, and was notified timely of Resident 16's weight loss on 1/2/24. The progress notes also failed to show the RD and Resident 16's responsible party were notified of the weight changes. On 1/25/24 at 1434 hours, an interview and concurrent medical record review were conducted with LVN 4. LVN 4 stated for the notification of changes, to notify the physician and the resident's responsible party immediately; and if needed, the physician would order an RD consult. LVN 4 reviewed Resident 16's Weight and Vitals Summary and verified Resident 16's weight gain on 12/26/23, and weight loss on 1/2/24. LVN 1 was unable to find documentation to show the physician, RD, and resident's representative were notified of the resident's weight gain. LVN 1 was unable to find documentation showing the 1/2/24 weight loss with timely notification to the physician and that the RD and resident's responsible party were notified. On 1/26/24 at 1112 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated they were Resident 16's primary emergency contact. Family Member 2 stated they were not notified by the facility of any weight gain or losses. On 1/26/24 at 1238 hours, a telephone interview was conducted with Resident 16's physician, Physician 1. Physician 1 stated he was notified of a weight gain and reviewed the resident's weight log. When asked if it was the weight on 1/9/24, with the note for positive edema, the physician stated yes, and that they wrote the note about edema.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the baseline care plans related to the fall risk was developed for one of 13 final sampled residents (Resident 379). This failure had the potential for the resident to not receive the necessary care and services in accordance with their care needs. Findings: Review of the facility's P&P titled Baseline Care Plans for New Residents dated 6/22 showed the baseline care plans should be completed upon admission based on the resident's individual needs. Medical record review for Resident 379 was initiated on 1/24/24. Resident 379 was admitted to the facility on [DATE]. Review of Resident 379's Order Summary Report for January 2024 showed a physician's order dated 1/22/24, to place the bilateral floor mats to prevent and/or minimize further injury from fall, and another physician's order for Joerns deluxe assist handle (a assistive device attached to the resident's bedframe to assist with mobility) times two for better positioning and transfers. Review of the Generations Post-Acute admission Data Collection dated 1/22/24, under the section Interim Care Plan on Falls, showed no information if Resident 379 was at risk for falls. Review of the Morse Fall Risk assessment dated [DATE], showed Resident 379 was assessed as a low risk for falling. Review of the baseline plan of care formulated upon admission of Resident 379 showed the specific care plans addressing the basic care needs of the resident. However, further review of the plan of care showed no documented evidence a baseline care plan was developed to address the fall risk, use of side rails, and bilateral floor mats. On 1/24/24 at 1400 hours, an interview for Resident 379 was conducted with CNA 4. CNA 4 verified Resident 379 had side rails installed on their bed. CNA 4 stated Resident 379 was not able to use the side rails in bed. On 1/25/24 at 1012 hours, an interview and concurrent medical record review for Resident 379 was conducted with LVN 4. LVN 4 verified there was a physician's order for Resident 379's use of side rails in bed and the floor mat on both side of the bed. LVN 4 stated Resident 379 was not able to move in bed due to pain. LVN 4 verified Resident 379 was assessed for a low risk for fall and the least restrictive intervention included a floor mat. LVN 4 verified there was no baseline care plan addressing the risk for fall with the use of side rail and floor mats. On 1/25/24 at 1019 hours, an interview and concurrent medical record review for Resident 379 was conducted with RN 1. RN 1 verified there was a physician's order for the use of the side rail. RN 1 verified there was no baseline care plan for fall and the use of the side rails in bed. On 1/25/24 at 1606 hours, an interview for Resident 379 was conducted with the DON. The DON was informed and verified the above findings.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 679 was initiated on 1/23/24. Resident 679 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 679's Order Summary Report showed a physician's order dated 1/18/24, to check PVR Q six hours, perform IN and OUT catheterization (a method of emptying the bladder) Q six Hours PRN if PVR more than 125 ml or equal, insert Foley catheter on the 3rd check every six hours for bladder training outcome for two days and notify MD of Outcome. Review of Resident 679's Plan of Care failed to show a care plan problem was developed to address the PVR monitoring as ordered by the physician. On 1/25/24 at 0755 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 acknowledged Resident 679's Plan of Care did not have a care plan problem to address the physician's order to check for PVR. Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive care plans to reflect the individual care needs for three of 13 final sampled residents (Resident 25, 330, and 679) when: * The facility failed to develop a comprehensive care plan for Resident 25's use of Risperdal (a medication used to treat a number of mental health disorders including psychosis.) and sertraline hcl (a medication used to treat certain mood disorders such as depression.) * The facility failed to develop a care plan problem to address Resident 330's use of sertraline hcl. * The facility failed to develop a care plan problem to address the PVR monitoring for Resident 679. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents. Findings: 1. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised March 2022 showed the comprehensive, person-care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Order Summary Report for December 2023 showed a physician's order dated 12/28/23, to administer Risperdal oral tablet 0.5 mg by mouth two times a day for paranoid delusions manifested by false accusation that someone taking her money and sertraline hcl oral tablet 25 mg by mouth one time a day for depression manifested by sadness. Review of the Order Summary Report for January 2024 showed the order for Risperdal 0.5 mg was changed on 1/4/24, to be administered one time a day for paranoid delusions manifested by false accusation that someone taking her money. Review of Resident 25's care plan dated 12/28/23, showed the resident used Risperdal medication. However, the care plan failed to show the interventions to monitor for the false accusation behavior and provide non-pharmacological interventions. In addition Resident 25's care plan failed to show the care plan problem to address the use of sertraline hcl medication for depression manifested by verbalization of crying, monitoring for its effect and any adverse drug reactions and non-pharmacological interventions. On 1/24/24 at 1515 hours, an interview and concurrent record review was conducted with LVN 5. LVN 5 verified the comprehensive care plan for Resident 25 did not include the monitoring of behavior manifestations related to Resident 25's use of Risperdal, and no care plan problem to address the resident's depression and use of sertraline hcl. On 1/24/24 at 1600 hours, an interview and concurrent record review was conducted with the MDS/RAI Coordinator. The MDS/RAI Coordinator verified Resident 25's comprehensive care plan failed to show the behavior manifestations related to Resident 25's use of Risperdal and a care plan problem to address for the resident's depression and use of sertraline hcl. On 1/25/24 at 1407 hours, an interview was conducted with the DON. The DON stated the comprehensive care plan should have been developed for Resident 25's use of Risperdal and sertraline hcl. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of the Order Summary Report showed a physician's order dated 1/16/24, to administer sertraline 50 mg one tablet a day for depression manifested by verbalization of sadness. Review of Resident 330's plan of care failed to show a care plan problem was developed to address Resident 330's use of the sertraline medication. On 2/11/22 at 0825 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated the residents' care plans were initiated on admission and revised when there were any changes to the resident's condition and treatment plan. LVN 4 reviewed Resident 330's care plan and verified the above findings. On 1/24/24 at 1542 hours, an interview and concurrent medical record review for Resident 330 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the nurse who placed the physician's order for the sertraline medication should have initiated the care plan for the medication.

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** 3. Review of the facility's P&P titled Fluid Intake and Output Monitoring dated 1/2021 showed the facility shall record output for the residents with indwelling urinary catheter. Medical Record Review for Resident 679 was initiated on 1/23/24. Resident 679 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the Resident's 679 Order Summary Report showed a physician's order dated 1/17/24, to monitor the resident's total urinary output in cc every shift. Review of Resident's 679's MAR for January 2024 showed the following recorded output: - On 1/20/24, for the day shift, 400 cc, - On 1/20/24, for the evening shift, 400 cc, - On 1/20/24, for the night shift, 680 cc, - On 1/21/24, for the day shift, none was recorded, - On 1/21/24, for the evening shift, 680 cc, - On 1/21/24, for the night shift, none was recorded, - On 1/22/24, for the day shift, 600 cc, - On 1/22/24, for the evening shift, 400 cc, and - On 1/22/24, for the night shift, 600 cc. On 1/25/24 at 0755 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 acknowledged there were missing output documented for the day and on evening shifts on 1/21/24. b. Review of the Order Summary Report showed a physician's order dated 1/18/24, with start date 1/24/24, and end date 1/26/24, to check PVR every six hours and perform IN and OUT catheterization every six hours PRN if PVR more than 125 ml or equal. However, further review of medical record showed no documented evidence the PVR was monitored as ordered. On 1/25/24 at 0755 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 acknowledged there was no record for PVR monitoring as ordered by physician. 2. Medical record review for Resident 8 was initiated on 1/24/23. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's H&P examination dated 10/13/23, showed Resident 8 did not have the capacity to understand and make her own decisions. a. Review of Resident 8's eInteract SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 12/28/23, showed upon body assessment, Resident 8 was noted to have yellow discharge from the G-tube site with no odor, afebrile, and non-tachycardic; and the dressing was changed. Review of Resident 8's Plan of Care dated 12/29/23, showed a care plan problem for infection of the G-tube site. The care plan interventions included to monitor/document/report to MD for changes in behavior, altered mental status, wide variation in cognitive function throughout the day, communication decline, disorientation, periods of lethargy, restlessness, agitation, and altered sleep. b. Review of Resident 8's eInteract SBAR Communication form dated 1/16/24, showed Resident 8 had a body temperature of 100 degrees Fahrenheit. Review of Resident 8's Plan of Care updated on 1/17/24, showed a care plan problem for UTI. The care plan interventions included to monitor/document/report to MD as needed for signs and symptoms of UTI: frequency, urgency, malaise, foul smelling urine, dysuria, fever, nausea and vomiting, flank pain, supra-pubic pain, hematuria, cloudy urine, altered mental status, loss of appetite, and behavioral changes. However, review of Resident 8's Change in Condition notes showed documentation of assessment only for the following dates: - 12/29/23, for 7-3 shift - 12/29/23, for 11-7 shift - 12/30/23, for 3-11 shift - 12/31/23, for 3-11 shift - 1/17/24, for 7-3 shift - 1/17/24, for 3-11 shift On 1/24/24 at 1029 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the abnormal vital signs and drainage from the G-tube site were considered a change in a resident's condition or status. RN 1 stated for a change in condition, the licensed nurse had to initiate a change in condition note documenting the assessment monitoring every shift for 72 hours. RN 1 verified there was no documentation of change in condition assessment monitoring for 72 hours for Resident 8's two change of conditions identified on 12/28/23 and 1/16/24. On 1/25/24 at 0855 hours, an interview was conducted with the DON. The DON stated when the licensed nurse identified a change in condition for a resident, the Change in Condition assessment monitoring had to be initiated every shift for 72 hours. The DON was notified of the missing documentation for the Change in Condition assessment monitoring for Resident 8. The DON acknowledged the above findings. Based on observation, interview, and medical record review, the facility failed to provide the services to attain or maintain the highest practicable well-being for three of 13 final sampled residents (Residents 8, 9, and 679). * Resident 9 was administered olmesartan medoxomil (medication to treat high blood pressure) and metoprolol (medication to treat high blood pressure) when Resident 9's systolic blood pressure was below the parameter prescribed by the physician. * The facility failed to continue to monitor and document assessment every shift for 72 hours after the change in condition identified for Resident 8. * The facility failed to ensure the physician's orders were followed related to monitoring of Resident 679's urinary output and PVR. These failures had the potential to negartively affect the residents' health condition and well-being. Findings: 1. Medical record review for Resident 9 was initiated on 1/23/24. Resident 9 was admitted to the facility on [DATE]. Review of Resident 9's Order Summary Report showed the following physician's orders: - On 10/4/23, to administer metoprolol tartrate 25 mg one tablet by mouth two times a day for hypertension (high blood pressure. Hold medication if systolic blood pressure less than 130 mmHg, or heart rate less than 60 beats per minute; and - On 10/25/23, to administer olmesartan medoxomil 40 mg one tablet by mouth every 48 hours for hypertension. Hold if systolic blood pressure less than 130 mmHg, or heart rate less than 60 beats per minute a. Review of Resident 9's MAR for November 2023 showed Resident 9 was administered the metoprolol medication when the resident's systolic blood pressure was below 130 mmHg as follows: - On 11/3/23 at 1700 hours, a blood pressure of 115/54 mmHg; - On 11/4/23 at 0900 hours, a blood pressure of 119/87 mmHg; - On 11/6/23 at 1700 hours, a blood pressure of 128/87 mmHg; - On 11/15/23 at 1700 hours, a blood pressure of 117/67 mmHg; - On 11/18/23 at 1700 hours, a blood pressure of 128/88 mmHg; - On 11/19/23 at 0900 hours, a blood pressure of 121/66 mmHg; - On 11/25/23 at 1700 hours, a blood pressure of 118/66 mmHg; and - On 11/26/23 at 0900 hours, a blood pressure of 122/66 mmHg. Review of Resident 9's MAR for December 2023 showed Resident 9 was administered the metoprolol medication when the resident's systolic blood pressure was below 130 mmHg as follows: - On 12/15/23 at 1700 hours, a blood pressure of 126/69 mmHg; - On 12/18/23 at 1700 hours, a blood pressure of 126/66 mmHg; - On 12/19/23 at 1700 hours, a blood pressure of 114/68 mmHg; - On 12/27/23 at 1700 hours, a blood pressure of 128/75 mmHg; and - On 12/30/23 at 1700 hours, a blood pressure of 118/62 mmHg. b. Review of Resident 9's MAR for January 2024 showed Resident 9 was administered the olmesartan medoximil medication when the resident's systolic blood pressure was below 130 mmHg as follows: 121/66 mmHg on 1/4/24, and 102/69 mmHg on 1/13/24. On 1/26/24 at 1026 hours, an interview and concurrent medical record review for Resident 9 was conducted with the DON. The DON verified the metoprolol and olmesartan medoximil medications were administered to Resident 9 when the resident's systolic was below the parameter prescribed by the physician. The DON stated the nurses should have held the metoprolol and olmesartan medoximil medications when Resident 9's systolic blood pressure was below 130 mmHg.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

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 follow the physician's order for the RD consult for one of 13 final sampled residents (Resident 16). * The RD did not review the resident's enteral feeding formula for more concentrated formula as ordered by the physician on 12/25/23, and failed to conduct the RD consultation for weight loss timely as ordered on 1/4/24, for Resident 16. This failure had the potential for a delay or dietary interventions putting the resident at risk of further undesirable outcomes. Findings: Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's History and Physical examination dated 12/4/23, showed the resident was unable to eat food by mouth and received nourishment through their G-tube. a. Review of Resident 16's MAR for December 2023 showed starting 12/7/23, Resident 16 received Glucerna 1.2 (an enteral feeding formula) via G-tube to run at 70 ml/hr for 20 hours. The record also showed to flush Resident 16's G-tube every six hours with 200 ml of water starting 12/6/23, and was discontinued on 12/25/23. Review of Resident 16's Physician's Progress Note dated 12/22/23, showed Resident 16 had hyponatremia (low sodium level in the blood) and the physician would monitor and consider a more dilute G-tube feedings and fluid restriction. a. Review of Resident 16's Order Summary Report showed a physician's order dated 12/25/23, for the RD to review if the resident's enteral formula could be changed to a more concentrated formula. A Physician's Order Note dated 12/25/23 at 1027 hours, showed RN 1 notified Physician 1 of Resident 16's laboratory results and received a physician's order to decrease the resident's water flushes and for the RD to see if Resident 16's enteral formula of Glucerna 1.2 could be changed to a more concentrated formula. A Physician's Order Note dated 12/25/23 at 1051 hours, showed RN 1 notified the RD of the new order for the RD to review Resident 16's enteral formula to see if it could be changed to a more concentrated formula, and of the order to decrease the resident's routine water flushes. * Further review of the medical record showed no documented evidence the RD had review the resident's formula for more concentrated formula as ordered by the physician. On 1/26/24 at 1014 hours, an interview and concurrent record review were conducted with RN 1. RN 1 reviewed Resident 16's medical record and was unable to find where the RD reviewed Resident 16's enteral formula to see if it could be changed to a more concentrated formula. On 1/26/24 at 1114 hours, a telephone interview was conducted with RD 2. RD 2 stated she was the owner of the facility's contracted dietetic consultant service. RD 2 stated when there was a physician's order for a RD consult, the standard of practice was to review the resident within 72 hours. On 1/26/24 at 1238 hours, a telephone interview was conducted with Physician 1. Physician 1 stated on 12/25/23, due to Resident 16's hyponatremia and laboratory results, he ordered for the water flushes to be decreased and for the RD to review if the resident could be changed to a more concentrated enteral formula. Physician 1 stated the purpose was to decrease Resident 16's fluid intake without decreasing their calorie intake. Physician 1 stated he had not received an update on it the RD reviewed if a more concentrated formula could be use. On 1/26/24 at 1335 hours, a telephone interview was conducted with RD 1. RD 1 stated Glucerna 1.5 was more concentrated than Glucerna 1.2. b. Review of Resident 16's Order Summary Report showed a physician's order dated 1/4/24, for RD consult for recent weight loss, for a weight of 142.6 lbs on 12/19/23, and 134.8 lbs on 1/2/24 (a 7.8 pounds weight loss in two weeks). Another physician's order dated 1/8/24, showed to refer to the RD to change enteral formula to bolus (to consolidate feedings and administer a larger quantity via a syringe or pump). Review of Resident 16's Nutrition Progress Note dated 1/10/24, showed the RD reviewed Resident 16's weight loss and recommended Glucerna 1.2, to give two cans (237 ml per can) bolus feeding TID (three times a day). The record failed to show the RD reviewed Resident 16's weight loss timely for the consult ordered on 1/4/24. On 1/26/24 at 1014 hours, an interview and concurrent record review were conducted with RN 1. RN 1 reviewed Resident 16's medical record and verified an order for a RD consult on 1/4/24. RN 1 stated the record showed the RD reviewed Resident 16 on 1/10/24, and changed the enteral feeding to bolus feedings. On 1/26/24 at 1114 hours, a telephone interview was conducted with RD 2. RD 2 stated when there was a physician's order for a RD consult, the standard of practice was to review the resident within 72 hours.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary enteral tube care and services for two of 13 final samples residents (Residents 16 and 629). * The facility failed to ensure Resident 629's J-tube placement was verified prior to the administration of medications. * Resident 16's enteral formula bottle was left at bedside after being opened. These failures posed the risk for developing complications related to enteral feeding. Findings: Review of the facility's P&P titled Administering Medications through an Enteral Tube revised 11/2018 showed steps in the procedure to verify placement of feeding tube prior to the administration of medication through enteral tube. On 1/23/24 at 1045 hours, an observation of medication administration was conducted with LVN 1. LVN 1 was observed to have instilled 15-20 cc of air through Resident 629's J-tube, without use a stethoscope . LVN 1 did not verify the placement of the J-tube prior to the administration of medication through the J-tube. Medical record review for Resident 629 was initiated on 1/23/24. Resident 629 was admitted to the facility on [DATE]. Review of Resident 629's Order Summary dated 1/24/24 showed a physician's order dated 1/13/24, to check placement of the J-tube before beginning a feeding and before administering medications. On 1/23/24 at 1456 hours, an interview was conducted with LVN 1. LVN 1 confirmed she failed to use a stethoscope to listen to verify J-tube placement. On 1/25/23 at 1520 hours, an interview was conducted with the DON. The DON stated the tube placement must be verified prior to the administration of medications. The DON was informed and acknowledged the above findings. 2. Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's MAR for January 2023, showed a physician's order effective 1/11/24, for an enteral feeding (formula administered directly to the stomach through a tube) of Glucerna 1.2, to give two cans TID (three times a day). On 1/23/24 at 0833 hours, Resident 16 was observed lying in bed. Resident 16's bedside table was observed to have an opened Glucerna 1.2 ready-to-hang bottle. The bottle was labeled 1500 ml and had markings on the side from 300 to 1500 ml, in 100 increments. The amount of the formula in the bottle was at the line marked 500 ml. Review of the manufacturer's guidance for Glucerna 1.2 showed the following: - for the 237 ml container, to refrigerate after opening. - for the ready-to-hang container, the instruction showed failure to follow the instructions for use, increase the potential for microbial contamination. Administer the formula with a feeding set and avoid touching any part of the container that comes into contact with the formula. On 1/23/24 at 1121 hours, an observation of Resident 16 was conducted. The opened Glucerna 1.2 enteral feeding ready-to-hang bottle was still on the resident's bedside table. On 1/23/24 at 1123 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 16 had a bolus enteral feeding. LVN 1 stated the facility did not currently have cans of the Glucerna 1.2 to administer to Resident 16, so the LVN was using the ready-to-hang bottle. The LVN stated they discarded the bottle daily. When asked if the bottle was safe at room temperature once opened and left at bedside, the LVN replied they believed it was because when they administered it with a feeding set, it was good for 24 hours. LVN 1 verified they were not using a closed feeding set to administer the formula, and punctured the bottle top where the feeding set would be inserted so they could pour it into a cup at each scheduled feeding. On 1/25/24 at 1125 hours, a telephone interview was conducted with the RD. The RD stated she was unable to find information to show Glucerna 1.2 in the ready-to-hang bottle was safe at room temperature when administered as a bolus, and not with a feeding set.

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

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 13 final sampled residents (Residents 429) received the appropriate care for peripheral intravenous catheter. * The facility failed to ensure Residents 429's IV site was assessed and monitored as per the facility's P&P. This failure posed the risk for a delay in identify and provide necessary care if the resident developed complications such as catheter-related infections. Findings: Review of the facility's P&P titled Administering Medications by IV Push revised 3/2022 showed assessment, inspect intravenous catheter site and system for signs of complications. On 01/23/24 at 0833 hours, an IV medication administration observation with RN 1 was conducted. RN 1 was observed cleansing Resident 429's IV port with alcohol wipes then proceeded with administering ceftriaxone (an antibiotic) 1 gm via IV pump. Medical record review for Resident 429 was initiated on 1/23/24. Resident was admitted to the facility on [DATE]. Review of Resident 429's Order Summary dated 1/17-1/24/23, showed a physician's order dated 1/17/24, to administer ceftriaxone 1 gm intravenously every 24 hours until 1/24/24. However, further review of the medical record failed to show documented evidence the resident's IV site was assessed and monitored for signs of complication as per the facility's P&P. On 1/25/24 at 1503 hours, an interview was conducted with the DON. The DON 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** 3. Review of the facility's P&P titled Oxygen Administration revised 1/1/21, showed to verify there is a physician's order for this procedure and review the physician's orders or facility protocol for oxygen administration. During the initial tour on 1/23/24 at 0858 hours, Resident 629 was observed in bed, sleeping. Resident 629's family member was in the room. Resident 629 had an oxygen concentrator machine. Resident 629's nasal cannula was observed on the floor. Resident 629's family member stated Resident 629 was using the nasal cannula on and off. Medical record review for Resident 629 was initiated on 1/23/24. Resident 629 was admitted on [DATE], and readmitted on [DATE]. Review of Resident 629's Order Summary Report showed a physician's order dated 1/12/24, for administering oxygen at 2-4 liters per minute via nasal cannula to keep oxygen saturation level above 90%. However the physician's order did not show if the oxygen administration was ordered for continuous or as needed. On 1/23/24 at 0915 hours, an observation and concurrent interview and medical record review was conducted with RN 1 and LVN 1. RN 1 and LVN 1 verified Resident 629's nasal cannula was in the floor. RN 1 checked Resident 629's oxygen saturation level and noted at 91%. LVN 1 stated when she assessed Resident 629 at 0800 hours, the oxygen saturation level was 93% on room air. RN 1 checked the order for Resident 629's oxygen and verified the order did not show whether to give the oxygen continuous or as needed. RN 1 stated the nurses had to verify with the physician if the oxygen administration was continuous or as needed. On 1/24/24 at 1015 hours, an interview was conducted with the IP. The IP stated the nasal cannula had to be in a bag labeled with the resident's name and date when not in use. The IP stated if the nasal cannula was found on the floor, it had been contaminated and had the potential to cause infection when used by the resident. On 1/25/24 at 0855 hours, an interview was conducted with the DON. The DON stated the licensed nurses were expected to verify the order for oxygen administration with indication to administer continuously or as needed. 2. Review of the facility's P&P titled Oxygen Administration dated 1/1/21, showed to verify if there is a physician's order for supplemental oxygen Medical record review for Resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Review of Resident 429's Order Audit Report dated 1/24/23, showed an order for oxygen at 2 lpm via nasal canula. The order failed to show if it was a continuous or PRN order. On 1/23/23 at 0831 hours, Resident 429 was observed lying in bed, on room air (without the use of supplemental oxygen). On 1/23/23 at 1223 hours, an interview was conducted with LVN 1 and Resident 429's bedside. LVN 1 verified the resident was on room air. LVN 1 was then pulled up Resident 429's physician's orders for oxygen and stated the order did not show if it was to be continuous or if it was PRN and the order needed to be clarified from the physician. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory services were provided as ordered for three of 13 final sampled residents (Residents 330, 429, and 629). * The facility failed to ensure Resident 330 received continuous oxygen via nasal cannula as per the physician's order. * Resident 429's physician's order for oxygen failed to show if the order was continuous or PRN. * Resident 629's nasal cannula was found in the floor and physician's order for oxygen failed to show if the order was continuous or as needed. These failures had the potential for these residents to not receive appropriate respiratory care and increase risks of infection. Findings: Review of the facility's P&P titled Oxygen Administration revised dated 10/2010 showed to verify there is a physician's order for this procedure and review the physician's orders of facility protocol for oxygen administration. 1. On 1/24/24 at 1044 hours, 1/25/24 at 0945 hours, and 1/26/24 at 0935 hours, Resident 330 was observed sitting in the wheelchair in her room. There was no oxygen provided via nasal cannula to Resident 330. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's Order Summary Report showed a physician's order dated 1/12/24, for continuous oxygen at one to two liters per nasal cannula, and may titrate to maintain oxygen saturation level above 90% every shift. On 1/26/24 at 0938 hours, an observation of Resident 330 and concurrent interview was conducted with CNA 4. Resident 330 was observed sitting in the wheelchair in her room. There was no oxygen provided via nasal cannula to Resident 330. CNA 4 verified Resident 330 did not have any oxygen provided via nasal cannula. On 1/26/24 at 0958 hours, an observation of Resident 330 and concurrent interview and medical record review for Resident 330 was conducted with LVN 6. LVN 6 verified Resident 300 had a physician's order for continuous oxygen at one to two liters per minute via nasal cannula. LVN 6 verified Resident 330 was not provided with oxygen via nasal cannula as ordered. On 1/26/24 at 1008 hours, an interview and concurrent medical record review for Resident 330 was conducted with the DON. The DON verified the above findings.

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** 5. On 1/26/24 at 0954 hours, an observation was conducted with Resident 629. Resident 629 was in bed and asleep. Resident 629's bed was observed with bilateral upper side rails elevated. Medical record review for Resident 629 was initiated on 1/26/24. Resident 629 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 629's H&P examination dated 1/14/24, showed Resident 629 had the capacity to understand and make decisions. The examination also indicated Resident 629 had general weakness. Review of Resident 629's Generations Initial Assistive Device Data Collection dated 1/12/24, showed the use of bilateral side rails for bed mobility and transfer purposes. Further review of Resident 629's medical record failed to show the physician's order and informed consent were obtained for the use of bilateral side rails. On 1/26/24 at 1000 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified Resident 629's bilateral side rails were elevated. LVN 2 stated Resident 629 used the side rails for mobility and turning in bed. LVN 2 stated before the use of side rails, the physician's order and consent should have been obtained, and the side rail and entrapments assessment should be completed. On 1/26/24 at 1003 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated when Resident 629 was readmitted to the facility, the new physician's order and consent should have been obtained for the use of side rails. RN 1 verified Resident 629 did not have the physician's order and consent for the use of side rails. On 1/26/24 at 1310 hours, an interview and concurrent medical record reviewed was conducted with the DON. The DON verified Resident 629 did not have the physician's order and consent obtained for the use of bilateral side rails. Based on observation, interview, medical record review, and facility P&P review, the facility failed to complete the entrapment assessments, obtain the physician's orders, and an informed consents prior to the use of side rails for five of 13 final sampled residents (Residents 9, 25, 330, 379, and 629). These failures had the potential to put the residents at risk for serious injuries. Findings: Review of the facility's P&P titled Bed Rails, Side Rails dated 4/12/21, showed the resident's assessment must include an evaluation of the alternatives that were attempted prior to the installation or use of a bed rail and how these alternatives failed to meet the resident's assessed needs. The resident assessment must also assess the resident's risk from using bed rails. The resident assessment should assess the resident's risk of entrapment between the mattress and bed rail or in the bed rail itself. Informed consent from the resident or resident representative must be obtained after appropriate alternative have been attempted prior to installation and use of bed rails. 1. On 1/23/24 at 0908 hours, and 1/24/24 at 0858 hours, Resident 25 was observed in bed with the left upper side rails elevated. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's History and Physical examination dated 12/29/23, showed Resident 25 had no capacity to understand and make decisions. Review of Resident 25's MDS dated [DATE], showed Resident 25 required substantial assistance of one staff for bed mobility and transfer. Review of Resident 25's Order Summary Report for January 2024, showed a physician's order dated 12/28/23, for Joerns deluxe (a assistive device attached to the resident's bedframe to assist with mobility) assist handle times two for better positioning and transfers. Review of Resident 25's Generations Initial Assistive Device Data Collection dated 12/28/23, showed the use of bilateral side rails for bed mobility and transfer purposes. Further medical record review for Resident 25 did not show documented evidence the informed consent for the use of the side rails were obtained, initiation of care plan for the use of side rails, and entrapment assessment prior to the installation of side rails. On 1/24/24 at 1337 hours, an observation and concurrent interview was conducted with CNA 3. CNA 3 verified Resident 25's bilateral side rails were elevated. CNA 3 stated Resident 25 used the side rails for pulling herself up in bed. On 1/25/24 at 1006 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 25 had a physician's order for the use of side rails. RN 1 verified there were no informed consent obtained, entrapment assessment, and care plan developed prior to installing the side rails. On 1/25/24 at 1609 hours, an interview for Resident 25 was conducted the DON. The DON was informed and verified the findings. Cross reference to F909, example #1. 2. On 1/24/24 at 0836 hours and 1/25/24 at 0846 hours, an observation and concurrent interview was conducted with Resident 379. Resident 379 was observed in bed with the upper side rails elevated. Resident 379 stated he was not able to use the side rails because he was in pain when he moved in bed. Medical record review for Resident 379 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 379's History and Physical examination dated 1/22/24, showed Resident 379 had the capacity to understand and make decisions. Review of Resident 379's Order Summary Report for January 2024 showed a physician's order dated 1/22/24, for Joerns deluxe (a assistive device attached to the resident's bedframe to assist with mobility) assist handle times two for better positioning and transfers every shift. Review of Resident 379's Generations Initial Assistive Device Data Collection dated 1/22/24, showed the use of bilateral side rail for bed mobility and transfers. Further medical record review for Resident 379 did not show documented evidence the informed consent for side rails were obtained, initiation of care plan for the use of side rails, and entrapment assessment prior to the installation of side rails. On 1/24/24 at 1400 hours, an interview for Resident 379 was conducted with CNA 4. CNA 4 verified Resident 379's use of the side rails. CNA 4 stated Resident 379 was not able to use the side rails in bed. On 1/25/24 at 1012 hours, an interview and concurrent medical record review for Resident 379 was conducted with LVN 4. LVN 4 verified there was a physician's order for Resident 379's use of side rails in bed. LVN 4 stated Resident 379 was not able to move in bed due to pain. On 1/25/24 at 1019 hours, an interview and concurrent medical record review for Resident 379 was conducted with RN 1. RN 1 verified there was a physician's order for the use of the side rails. RN 1 verified there were no informed consent, entrapment assessment, and care plan developed prior to installing the side rails. On 1/25/24 at 1606 hours, an interview for Resident 379 was conducted the DON. The DON was informed and verified the above findings. Cross reference to F909, example #2. 3. On 1/23/24 at 0924 hours, 1/24/24 at 1044 hours, and 1/25/24 at 0945 hours, bilateral assist rails were observed on Resident 330's bed. On 1/25/24 at 0932 hours, an interview for Resident 330 was conducted with CNA 5. When asked about Resident 330's use of the assist rails, CNA 5 stated Resident 330 used the assist rails during turning and repositioning. On 1/25/24 at 0945 hours, Resident 330 was observed sitting in the wheelchair in her room. Bilateral assist rails were observed elevated. When asked about the bilateral assist rails, Resident 330 stated she used the assist rails for turning and repositioning while in bed. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was admitted to the facility on [DATE]. Review of Resident 330's History and Physical examination dated 1/15/24, showed Resident 330 did not have the capacity to understand and make decisions. Review of Resident 330's Generations Initial Assistive Device Data Collection dated 1/12/24, did not show any entrapment assessment was conducted related to the use of the assist rails. Further review of the medical record showed no documented evidence a physician's order was obtained and a care plan problem was initiated related to the use of side rails for Resident 330. On 1/25/24 at 0950 hours, an interview and concurrent medical record review for Resident 330 was conducted with RN 1. When asked about the assist rails, RN 1 verified there was no physician's order obtained, care plan was not initiated and no entrapment assessment conducted related to the use of assist rails for Resident 330. Cross-reference to F909, example #3. 4. On 1/23/24 at 0959 hours, 1/24/24 at 1338 hours, and 1/25/24 at 0905 hours, bilateral assist rails were observed on Resident 9's bed. On 1/24/24 at 1338 hours, Resident 9 was observed sitting in the wheelchair in her room. Bilateral assist rails were observed elevated. When asked about the bilateral assist rails, Resident 9 stated she used the assist rails when she gets out of bed. Medical record review for Resident 9 was initiated on 1/23/24. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's MDS dated [DATE], showed Resident 9 had moderate cognitive impairment and required partial/moderate assistance for bed mobility. Review of Resident 9's Order Summary Report showed a physician's order dated 10/2/23, for the Bilateral Joerns deluxe assist handle rails for better repositioning and transfer while in bed. Review of Resident 9's Generations Initial Assistive Device Data Collection dated 9/27/23, did not show any entrapment assessment was conducted related to the use of the assist rails. Review of Resident 9's plan of care showed a care plan problem dated 9/28/23, to address Resident 9's use of the assist rails bilaterally to aide with bed mobility. The interventions/tasks included to ensure a valid consent on chart prior to initiating the assist rails and evaluate the resident's ongoing appropriateness for use of the assist rails for bed mobility. Further review of the medical record showed no documented evidence an informed consent was obtained prior to initiating the use of side rails for Resident 9. On 1/25/24 at 0931 hours, an interview for Resident 9 was conducted with CNA 5. When asked about Resident 9's use of the assist rails, CNA 5 stated Resident 9 used the assist rails when getting up from bed and during turning and repositioning. On 1/25/24 at 0959 hours, an interview and concurrent medical record review for Resident 9 was conducted with RN 1. When asked about the consent for assist rails, RN 1 verified there were no consent obtained and entrapment assessment conducted prior to the use of the assist rails for Resident 9. Cross reference to F909, example #4.

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 for one of 13 final sampled residents (Resident 629) and one nonsampled resident (Resident 23) to meet the needs of each resident as evidenced by: * The facility failed to ensure the medications were administered as ordered to Resident 629. * The facility failed to ensure the controlled drug, hydrocodone-acetaminophen 10 mg-325 mg tablet,signed out from the controlled drug record were documented as administered on the MAR for Resident 23 * The facility failed to ensure the disposed medications were destructed and mixed with undesirable substance or a medication destroyer chemical. These failures had the potential for poor health outcomes to the residents and controlled medications diversion. Findings: 1. On 1/23/24 at 0903 hours, medication administration observation was conducted with LVN 1. LVN 1 was observed administering one medication via J-Tube to Resident 629. Resident 629 was given 3 ml of oxycodone (a narcotic analgesic) 5 mg/5 ml. On 1/23/24 at 1045 hours, medication administration observation was conducted with LVN 1. LVN 1 was observed administering the following two medications via J-tube to Resident 629: - Gabapentin (works in the brain to prevent seizures and relieve pain for certain conditions in the nervous system) 600 mg one tablet. - iron (a mineral the body needs for growth and development) 65 mg one tablet. Medical record review for Resident 629 was initiated on 1/23/24. Resident 629 was admitted to the facility on [DATE]. Review of Resident 629's Order Summary dated for January 2024 showed the following physician's orders: - on 1/13/24, calcium carbonate antacid oral tablet chewable 500 mg one tablet via J-tube one time a day for supplement. - on 1/13/24, Coenzyme Q10-Vitamin E oral tablet chewable 100-300 mg- unit one tablet via J-tube one time a day for supplement - on 1/15/24, ferrous sulfate oral tablet 325 (65 mg) one tablet via J-tube one time a day for supplement - on 1/12/24, multivitamin with minerals oral liquid 5 ml via J-tube one time a day for supplement - on 1/15/24, nebivolol hcl oral tablet 10 mg 0.5 tablet via J-tube one time a day for hypertension hold if systolic blood pressure less than 105 mmHg or heart rate less than 60 bpm - on 1/15/24, potassium chloride oral solution 20 meq/15 ml (10%) 7.5 ml via J-tube one time a day for supplement with four to eight ounces of water to prevent gastric irritation - on 1/13/24, PreserVision Areds two capsules via J-tube for supplement - on 1/13/24, calcium-cholecalciferol oral tablet 500-5 mg-mcg one tablet via J-tube two times a day for supplement - on 1/15/24, docusate sodium oral tablet 100 mg one tablet via J-tube two times a day for bowel management - on 1/15/24, dorzolamide hcl ophthalmic solution 2% instill one drop in both eyes two times a day for eye maintenance wait five minutes between each drop to prevent wash out of previous eye drop - on 1/15/24, Timolol Maleate Ophthalmic Solution 0.5 % instill one drop in both eyes two times a day for eye maintenance wait for five minutes between each drop to prevent wash out of previous eye drop - not given - lunch time - on 1/13/24, gabapentin oral tablet 600 mg one tablet via J-tube three times a day for pain management - on 1/22/24, oxycodone hcl oral solution 5 mg/5 ml 3 ml via J-tube every four hours for pain moderate to severe pain. Give 3 ml via J- tube every four hours as needed for moderate to serve pain - on 1/15/24, benazepril hcl oral tablet 10 mg four tablets via J-tube one time a day for hypertension. Hold if systolic blood pressure less than 105 mmHg or heart rate less than 60 bpm On 1/23/24 at 1456 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 stated she had given some of Resident 629's medication at 0730 hours, prior to the observation of medication administration at 1045 hours, because the resident did not want to take all medications at the same time. LVN 1 was asked to show the medications given at 0730 hours. LVN 1 showed the medication supply and stated the medications given to Resident 629 were as follows: - calcium carbonate oral tablet gave ultra strength 1000 mg - Coenzyme Q10-Vitamin E 10 ml - multivitamin with mineral one tablet - PreserVision AREDS two chewable tablets - potassium chloride oral solution 20 meq/15 ml - calcium 600 mg tablet - vitamin D 25 mcg (1000 unit) one tablet - docusate sodium oral 100 mg one tablet - dorzolamide hcl ophthalmic solution 2 % one drop in both eyes was given before lunch time - timolol maleate ophthalmic solution 0.5 % instill one drop in both eyes given before lunch time - benazepril hcl oral tablet 10 mg four tablets (was not given due to blood pressure reading was 104/65 mmHg) - nebivolol hcl Oral Tablet 10 mg (Nebivolol HCl) 0.5 tablet (was not given due to blood pressure reading was 104/65 mmHg) LVN 1 verified Resident 629 were given the following medications via J-tube which were not according to the physician's orders: - calcium carbonate oral tablet gave ultra strength 1000 mg was given instead of 500 mg - multivitamin with minerals tablet was given instead of liquid form - calcium 600 mg was given instead of 500 mg - Coenzyme Q10-Vitamin E 10 ml liquid instead of oral chewable tablet form - PreserVision AREDS capsule was given instead of chewable tablets On 1/25/24 at 1503 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. 2. On 1/24/24 at 1050 hours, review of Resident 23's hydrocodone-acetaminophen 10 mg-325 mg tablet Controlled or Antibiotic Drug Record showed one tablet was taken on the following dates and times: - 1/4/24 at 1430 hours; - 1/12/24 at 1800 hours; and - 1/21/24 at 1700 hours However, review of Resident 23's MAR for January 2023 showed the above hydrocodone-acetaminophen 10 mg-325 mg tablet removed from the controlled drug record were not documented as administered. On 1/24/24 at 1050 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified the above findings. On 1/25/24 at 1510 hours, an interview was conducted with the DON. The DON stated the licensed nurses were expected to sign out the narcotic medication and document the administration of the narcotic medication in the MAR after the medication was given to the resident. The DON was informed and acknowledged findings. 3. Review of facility's P&P titled Discarding and Destroying Medications revised November 2022 showed non controlled and schedule V (nonhazardous) controlled substances are disposed of in accordance with the state regulations and federal guidelines regarding disposition of non-hazardous medications. For unused non-hazardous controlled substances that are not disposed by an authorized collector, the Environmental Protection Agency (EPA) recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the mixture in the sealable bag, empty can, or other container to prevent leakage. On 1/24/24 at 0924 hours, a concurrent observation and interview was conducted with the DON. A white bin with about one-third full of medications was observed with whole tablets and capsules accessible inside the medication room. The DON stated these medications were disposed and should have the drug destroyer chemical poured into the bin. The DON poured three half gallon bottles of a drug destroyer chemical and poured some water right away.

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 13 final sampled residents (Resident 25) was provided the management for the use of psychotropic medications (medications that affect the mind, emotions, and behavior). * The facility failed to ensure non-pharmacological approaches to care were provided for Resident 25 while receiving risperidone (Risperdal, a medicine that helps with symptoms of some mental health conditions where someone may see, hear, or feel things that are not there or believe things that are not true or you feel unusually suspicious) and sertraline (Zoloft, a medication used to treat depression). This failure had the potential to cause harm to Resident 25. Findings: Review of facility's P&P titled Use of Psychotropic Medication dated 5/23/23, showed the residents who use psychotropic drugs shall receive non-pharmacological interventions to facilitate reduction or discontinuation of the psychotropic drugs. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Order Summary Report for December 2023 showed a physician's order dated 12/28/23, to administer Risperdal oral tablet 0.5 mg by mouth two times a day for paranoid delusions manifested by false accusation that someone taking her money and sertraline hcl oral tablet 25 mg by mouth one time a day for depression manifested by sadness. Review of the Order Summary Report for January 2024 showed the order for Risperdal was changed on 1/4/24, to Risperdal oral tablet 0.5 mg by mouth one time a day for paranoid delusions manifested by false accusation that someone taking her money. Review of Resident 25's MAR for December 2023 and January 2024 showed Resident 25 had received Risperdal and sertraline hcl daily since admission. There was no documented evidence of non-pharmacological interventions provided for the resident. Further review of Resident 25's care plan problem addressing the use of Risperdal and sertaline hcl medications failed to show documentation of interventions for non-pharmacological implementation for the use of the above medications. On 1/24/24 at 1458 hours, a concurrent observation and interview with Resident 25 was conducted. Resident 25 was lying in bed. Resident 25 denied sadness and stated she felt fearful at times. On 1/25/24 at 0922 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated the residents on psychotropic medications should be provided with non-pharmacologic interventions and should be documented in the MAR. Further review of Resident 25's MAR failed to show non-pharmacologic interventions provided for the use of Risperdal and sertraline hcl. On 1/25/24 at 1407 hours, an interview conducted with the DON. The DON was informed and acknowledged above findings.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the medication error rate was below 5%. The facility's medication rate was 18.52%. Two of two licensed nurses (LVNs 1 and 3) observed administering the medications was found to have errors while administering the medications to four nonsampled residents (Resident 14, 17, 23, and 630). * The facility failed to ensure Resident 17 received the prescribed eye drops in accordance with the facility's P&P. * The facility failed to ensure Resident 14's inhalation medication was administered in accordance with the facility's P&P. *The facility failed to ensure Resident 25's hydroxychloroquine (a medication used to treat discoid lupus erythematosus (a chronic inflammatory condition of the skin) was given with food or meal. * The facility failed to ensure Resident 630's blood pressure was obtained just before giving the medications to control the blood pressure. * The facility failed to ensure Resident 630's Peridex (oral rinse for use between dental visits as part of a professional program for the treatment of gingivitis- inflammation of the gums) mouth or throat solution was given as prescribed by the physician. These failures had the potential for the residents developing complications and ineffective therapeutic effects of the medications. Findings: 1. Review of the facility's P&P titled Instillation of Eye Drops dated 1/2014 showed steps in the procedure to gently pull the lower eyelid down, instruct resident to look up. Drop the medication into the mid lower eyelid. (Note do not touch the eye or eyelid with the dropper). Recap the medication bottle. Instruct the resident to slowly close his/her eyelids to allow for even distribution of the drops. Medical record review for Resident 17 was initiated on 1/23/24. Resident 17 was admitted to the facility on [DATE]. On 01/23/24 at 0930 hours, a medication administration observation was conducted with LVN 3. LVN 3 administered one drop of dorzolamide hcl and timolol malate (eye drops used to treat increased pressure in the eye caused by glaucoma) ophthalmic solution directly on Resident 17's both eyes. LVN 3 did not pull down the resident's lower eyelid as per the facility's P&P. Review or Resident 17's Order Summary Report for 1/2024 showed a physician's order dated 12/28/23, for dorzolamide hcl and timolol malate ophthalmic solution 0.5%, instill 1 drop in both eyes two times a day for increased eye pressure. On 1/23/24 at 1513 hours, an interview was conducted with LVN 3. LVN 3 stated she instilled one drop of dorzolamide hcl and timolol malate ophthalmic solution 0.5% to Resident 17's both eyes; however, failed to pull down the lower eyelids. On 01/25/23 at 1503 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 2. Review of the facility's P&P titled Administering Medication through a Metered Dose Inhaler revised 10/2010, showed steps in the procedure ask the resident to inhale and exhale deeply for few breath cycles. On the last cycle, instruct the resident to exhale deeply then place the mouthpiece in the mouth and instruct the resident to close his or her lips to form a seal around the mouthpiece. Firmly depress the mouthpiece against the medication canister to administer medication. Instruct the resident to inhale deeply and hold for several seconds. Remove the mouthpiece from the mouth and instruct the resident to exhale slowly though pursed lips. Repeat the inhalation, if ordered. Allow at least one minute between inhalations of the same medications and at least two minutes between inhalations of different medications. Medical record review for Resident 14 was initiated on 1/23/24. Resident was admitted to the facility on [DATE]. Review or Resident 14's Order Summary Report for 1/2024 showed a physician's order dated12/28/23, for Breztri Aerosphere Inhalation Aerosol (a medication used long term to treat people with COPD. It improves symptoms of COPD for better breathing and to reduce the number of flare-ups) 160 mg - 9 mcg - 4.8 per inhalation, give 2 inhalations orally two times a day for COPD, and to rinse mouth with water after use. On 01/23/24 at 0933 hours, a medication observation was conducted with LVN 3. LVN 3 administered two inhalations of Breztri Aerosphere Inhalation Aerosol 160 mg - 9 mcg - 4.8 per inhalation to Resident 14. Upon administration of the Breztri Aerosphere Inhalation, LVN 3 placed the mouthpiece of the medication to Resident 14's mouth. LVN 3 counted one to three then administered the first inhalation to Resident 14. Resident 14 was not observed to take breaths and to inhale deeply upon administration of the medication. LVN 3 removed the Breztri Aerosphere Inhalation from Resident 14's mouth. LVN 3 then proceeded to place the Breztri Aerosphere Inhalation mouthpiece back to Resident 14's mouth again for the second inhalation. LVN 3 counted one to three. Resident 14 was not observed to take cycle of breaths and did not inhale deeply as medication was being administered. Right after the Breztri Aerosphere Inhalation mouthpiece was removed from the Resident 14's mouth, the resident started talking. LVN 3 failed to provide instructions to the resident to inhale and exhale deeply for few breath cycles prior to the administration of the medication. Resident 14 was not observed to hold breaths and exhale slowly with pursed lips after receiving the inhalation. Resident 14 talked right after the mouthpiece was removed from Resident 14's mouth. LVN 3 did not allow at least one minute in between inhalations of the medication. On 01/23/24 at 1513 hours, an interview was conducted with LVN 3. LVN 3 stated she was not able to give instructions to Resident 14 to take deep breaths. LVN 3 stated she usually gave time prior to the administration of the second inhalation. However, LVN 3 was not able to wait during the medication administration. LVN 3 verified Resident 14 talked right after the second inhalation was administered. On 01/25/23 at 1503, an interview with the DON was conducted. The DON was informed and acknowledged the above findings. 3. According to Lexicomp by Wolters and Kluwer, provides evidence-based drug information for clinicians and patients with complex conditions, hydroxychloroquine or systemic lupus erythematosus (an autoimmune disease in which the immune system attacks healthy parts of the body such as joints, skin, blood vessels, and organs) and rheumatoid arthritis.) must be administered with food or milk. Do not crush or divide film-coated tablets per the manufacturer. Medical record review for Resident 23 was initiated on 1/23/24. Resident 23 was admitted to the facility on [DATE]. Review of Resident 23's Order Summary Report for 1/2024 showed a physician's order dated 1/22/24, to administer hydroxychloroquine 200 mg one tablet by mouth two times a day. On 1/23/24 at 0956 hours, a medication administration observation was conducted with LVN 3. LVN 3 was observed administering hydroxychloroquine 200 mg one tablet to Resident 23. Resident 23 did not have food or meal upon administration of the medication. On 1/23/24 at 1513 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 23 had breakfast at 0800 hours. LVN 3 acknowledged the hydroxychloroquine 200 mg one tablet was not administered with food or meal in accordance to the medication label. On 01/25/23 at 1503 hours, an interview was conducted with the DON. The DON was informed and acknowledged above findings. 4. Medical record review for Resident 630 was initiated on 1/23/24. Resident was admitted to the facility on [DATE]. Review of Resident 630's Order Summary dated for 1/2024 showed the following physician's orders dated: - 1/20/24, for amlodipine besylate (a medication used for treatment of hypertension) oral tablet 10 mg, give one tablet by mouth one time a day. Hold for SBP less than 105 mmHg. -1/20/24, for hydralazine hcl (a medication used for treatment of hypertension.) oral tablet 25 mg, give one tablet by mouth three time a day. Hold for SBP less than 105 mmHg. On 1/23/24 at 1019 hours, a medication administration observation and concurrent interview was conducted with LVN 1. LVN 1 was observed administering amlodipine besylate 10 mg one tablet and hydralazine hcl oral tablet 25 mg to Resident 630. LVN 1 stated Resident 630's BP was 116/88 mmHg at 0730 hours. LVN 1 further stated she usually took the residents' vital signs in the morning before she started passing medications. Further review of Resident 630's MAR showed a blood pressure of 116/88 mmHg was documented on 1/23/24 at 0900. On 01/25/23 at 1503, an interview with the DON was conducted. The DON was asked regarding procedure of taking blood pressure for medications with the prescribed parameters for blood pressure. The DON stated the blood pressure and heart rate should be taken just before giving the prescribed medication. The DON was informed and acknowledged above findings. 5. Medical record review for Resident 630 was initiated on 1/23/24. Resident 630 was admitted to the facility on [DATE]. On 1/23/24 at 1019 hours, a medication administration observation was conducted with LVN 1. LVN 1 verified Resident 630 would be given 12 tablets/capsules of 10 different medications. LVN 1 was observed to have given the following medications: - Aspirin Enteric Coated 81 mg one tablet - Ubiquinol 100 mg one soft gel - docusate sodium 100 mg one soft gel - levetiracetam 500 mg two tablets - amlodipine besylate 10 mg one tablet - Vitamin D 25 mg (1000 IU) one tablet - allopurinol 100 mg one tablet - acetaminophen 325 mg two tablets - rosuvastatin calcium 20 mg one tablet - hydralazine hcl 25 mg one tablet A medication reconciliation review, post medication administration observation, was conducted for Resident 630. Resident 630 had a physician's order dated 1/20/24, for Peridex mouth/throat solution 0.12 % give 15 ml by mouth every 12 hours for oral care swish and spit out. The Peridex was not administered during the medication administration observation with LVN 1. On 1/23/24 at 1456 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified she did not administer the Peridex mouth or throat solution as ordered by the physician.

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 properly stored and labeled. * The facility failed to ensure the discontinued medication was locked and not left unattended on top of the medication cart. * The facility failed to monitor the temperature of the resident's refrigerator in the medication room. * The facility failed to appropriately label multiple ointments with open date, dispose of the prescription ointments such as triamcinolone and mupirocin, dispose of the expired solutions, and maintain cleanliness of the treatment cart. * The facility failed to dispose opened sterile packages for IV therapy such as IV holder or lock and transparent dressing from the IV cart. * The facility failed to appropriately label the bottle of the iron tablets (supplement) and eye medication drops with open date. * The facility failed to dispose of the insulin pen beyond the used by date. * The facility failed to store the external and internal medications separately. These failures had the potential to negatively impact the residents' well-being. Findings: On 1/23/24 at 1044 hours, a concurrent medication administration observation and interview was conducted with LVN 1. LVN 1 was observed leaving Resident 29's Baclofen (a muscle relaxant) in a medication bubble pack card on top of the medication cart unattended and unsecured while passing medication to another resident. LVN 1 stated the medication was discontinued and was not supposed to be left on top of the medication cart. On 1/24/24 at 0808 hours, an inspection of the medication storage and labeling in the medication room and concurrent interview was conducted with the IP/DSD. The temperature for the freezer for the resident's food was not being monitored. The IP/DSD stated the freezer temperature should have been monitored. On 1/24/24 at 0829 hours, an inspection of the medication storage and labeling of the treatment cart was conducted with LVN 4 with the following findings verified with LVN 4: - one opened tube calmoseptine cream with no open date - two opened bottles of Nu gauze packing strip with open date - house supply - 15 days - one Dyna wound cleanser spray with no open date and resident name - one opened tube Remedy clinical protect no open date and resident name - two opened tube Remedy clinical moisturizer with no open date - one opened Triad hydophilic wound dressing with no open date and resident name - one opened tub Aquaphor Healing ointment no open date - one opened tube cream barrier no open date - one opened solosite wound gel - two opened tube antifungal greaseless cream - three opened tubes of triamcinolone acetate 0.1% with prescription label peeled off - one opened tube mupirocin 2% with no label - one opened tube hydrocortisone cream with no open date - Dakins solution 16 oz had expired on 6/23. - Hydrogen peroxide 16 oz 3% had expired on 6/23. - Aerosol foam sanitizer had expired on 10/22 - scattered powder in a bin in the 3rd drawer of the treatment cart On 1/24/24 at 0859 hours, an inspection of the medication storage and IV cart was conducted with RN 1 with the following findings verified with RN 1: - one IV holder/lock was opened. - one opened transparent dressing small in the 3rd IV drawer. - one opened transparent dressing medium in the 3rd IV drawer. - one pack of good wipes, 60 wipes, had expired on 4/2023. On 1/24/24 at 1050 hours, an inspection of the medication storage and Medication Cart 2 was conducted with LVN 3 with the following findings verified with LVN 3: - An opened bottle of iron 65 mg tablets (supplement) with no open date. - An open brimonidine tartrate eye drops (used to treat open-angle glaucoma or high fluid pressure in the eye) with no open date. - An Insulin Lispro injection 100 units (used for diabetic) labeled with the open date of 12/22/23, past 28 days from the open date - Liothyroxone (used for hypothyroidism) and progesterone capsules (hormone supplement) were stored with topical estradiol (use to treat changes in and around the vagina caused by low estrogen levels or menopause) in a zip lock bag. On 1/25/23 at 1510 hours, an interview was conducted with the DON. The DON stated the medications such as ointments, creams, and tablets should have been labeled with an open date. The DON verified the opened sterile items must not be stored in the IV medication cart. The DON verified the insulin pen was good only for 28 days after the open date. The DON verified the external and internal medications should be stored in different areas. The DON was informed and acknowledge the above findings.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and the facility P&P review, the facility failed to ensure the kitchen staff had the appropriate skill set to safely perform the daily operation of the Food and Nutrition Services Department. * Dietary Aides 1 and 2 were unable to demonstrate the thermometer calibration procedure. * Dietary Aide 1 used the wrong strip to test the chemical concentration measured in parts per million of quaternary sanitizing solution used to sanitize food contact surfaces, and to test the chlorine concentration of the dish machine. * Dietary Aide 2 was unable to correctly describe how to manually wash dishes. These failures had the potential to lead to foodborne illnesses in a highly susceptible population of residents who received food prepared in the kitchen. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. Review of the facility's P&P titled Operation and Sanitation revised date 8/31/18, showed to document the training of al meployees in the use of kitchen equipment using the Competency Checklists (Forms 711-715 or other designated form) and Dietary Employee Orientation Guide (Form 717 or other designated form). 1. According to the USDA Food Code 2022, 4-502.11(B), Good Repair and Calibration, showed food temperature measuring devices shall be calibrated in accordance with the manufacturer's specifications as necessary to ensure their accuracy. Review of the facility's P&P titled How to Calibrate Thermometers: Bi-metallic Stem and Digital revised 12/12/19, showed the procedure on how to calibrate either a bi-metallic stem or a digital thermometer and to understand the importance of calibration because it resets the thermometer to read accurately. Review of the [NAME] Waterproof Digital Thermometer Instruction Manual (undated) showed the digital thermometers that have a bead type thermistor (a resistance thermometer, or a resistor whose resistance is dependent on temperature) sensor seldom require a calibration or testing. Nevertheless, it is desirable to calibrate to a specific temperature. On 1/24/24 at 1124 hours, during the trayline observation, the dietary staff were asked to perform a thermometer calibration with the CDM and the Culinary Director present. When asked to do a thermometer calibration, Dietary Aide 1 did not perform a thermometer calibration but checked the food temperature with a digital thermometer. Dietary Aide 2 was then asked to perform a thermometer calibration, Dietary Aide 2 answered yes but continued to check the food temperature with a digital thermometer. When asked about the thermometer calibration, the CDM stated they did not perform calibration of the digital thermometers. 2. According to the USDA Food Code 2022, 4-501.116, Warewashing Equipment, Determining Chemical Sanitizer Concentration, showed the concentration of the sanitizing solution shall be accurately determined by using a test kit or other device. According to the USDA Food Code 2017, 4-301.12, Manual Ware washing, sink compartment requirements, alternative manual ware washing equipment must provide accomplishment of the application of cleaners and the removal of soil, removal of any abrasive and removal or dilution of cleaning chemicals and sanitation. On 1/24/24 at 1403 hours, an observation and interview were conducted with Dietary Aide 1 and the CDM. The following was observed: a. Dietary Aide 1 was asked to demonstrate how to check the sanitizing solution of the dishwasher. Dietary Aide 1 was observed using a pH strip and dipped the strip into the dish surface on the final rinse. b. Dietary Aide 1 was then asked to demonstrate how to check the sanitizing solution in the sanitation bucket. Dietary Aide 1 was observed using the chlorine test strips and dipped the strip into a red bucket filled with sanitizer. The testing strip color did not change. Dietary Aide 1 repeated the steps and the strip color still did not change. The CDM verified Dietary Aide 1 used the wrong test strips to check the sanitizing solution in the red bucket and dishwasher. The CDM stated the chlorine test strip should be used to check the sanitizing solution of the dishwasher, and the pH testing strip should be used to check the sanitizing solution in the red bucket. 3. According to the Food Code 2022, 4-301.12, Manual Warewashing, Sink Compartment Requirements, showed the three-compartment requirement allows for proper execution of the three-step manual warewashing procedure. If properly used, the three-compartments reduce the change of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Review of the facility's P&P titled How to Clean and Sanitize Pots, Pans, Utensils and Dishes revised 1/17/19, showed the following: - Fill appropriate temperature water to fill lines. Add appropriate amount of detergent and sanitizer. Test and record on Pot and Pan Litmus Test Log. Scrape and flush out food particles; - Wash with detergent (110-120 degrees F). Change water every 30 minutes; - Rinse (110-120 degrees F). Change water frequently; - Sanitize. Test with appropriate litmus test paper and leave in sanitizing solution for appropriate contact time; and - Air dry. Do not towel. Inspect and store dry. On 1/24/24 at 1607 hours, an interview was conducted with Dietary Aide 2 and with the CDM present. Dietary Aide 2 was asked the procedure for manual handwashing in the three-compartment sink. Dietary Aide 2 stated they soaked the dishware with soap and water, sanitized by dunking it in for a little bit and then rinsed the dishware with water. When Dietary Aide 2 was asked if he had a training on manually washing the dishware using the three-compartment sink, Dietary Aide 2 answered he was not really trained, but it was based on experience. On 1/24/24 at 1610 hours, an interview was conducted with the CDM. When asked if any trainings were conducted on performing thermometer calibration, checking the sanitizing solution of the dish machine and sanitizing buckets, and performing manual dish washing using the three-compartment sink, the CDM stated these competency skills were part of the dietary staff orientation and competency training. However, the CDM was not able to show documentation of the orientation and competency trainings. On 1/25/24 at 1500 hours, an interview was conducted with the Culinary Director. When asked what trainings were provided to the staff, the Culinary Director stated she conducted the trainings last year in January, however, she had thrown away the training documentation.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/23/24 at 1240 hours, a concurrent meal observation and interview was conducted with Resident 632 in his room. Resident 632 complained his meal tray was missing some of the food he ordered, and he received a food he did not order. Resident 632's meal ticket showed cob salad, cucumbers, fruit x3, and ice cream x3 marked off. Resident 632's meal tray was observed with missing cobb salad, cucumbers, fruit x3, and ice cream x3 and there was a light orange pureed food in a small bowl that was not listed in the meal ticket. The Culinary Director came to the room and verified there were missing food listed in the meal ticket and there was a pureed food which was a butterscotch pudding in the tray that was not listed. Medical record review for Resident 632 was initiated on 1/23/24. Resident 632 was admitted to the facility on [DATE]. Review of Resident 632's H&P examination dated 12/27/23, showed Resident 632 had the capacity to understand and make his own decisions. On 01/25/24 at 0930 hours, an interview was conducted with the Culinary Director who oversaw the resident menu and meals. The Culinary Director stated the meal tickets were based off the menu she created for the month. She stated the CNAs met with the residents daily to obtain their meal preferences and check off the food items on the meal ticket for meals on the following day. If the residents did not want the food items on the meal ticket, they would choose from the menu. The meal ticket was based on what the residents said they wanted for their meal. The Culinary Director stated all the food or food substitutions listed on a resident's meal ticket should be served to ensure the resident received their necessary caloric intake. The Culinary Director further stated it was necessary to follow the resident's preferences. Based on observation, interview, and facility document review, the facility failed to ensure the menu and recipes were followed. * The recipe for the mixed green salad was not followed when cucumbers were not served with the mixed green salad. * The lunch meal ticket for Resident 30 was not followed when she was not served with apple juice. * Resident 632 was not provided with the food he ordered as listed on the meal ticket, and received a food he did not order. These failures had the potential for the residents not receiving adequate nutrition, and appropriate food texture based on their diet. Findings: 1. Review of the facility's Diet Type Report dated 1/24/24, showed 25 of the 34 residents residing in the facility received regular-textured food prepared in the kitchen. Review of the facility's document titled Daily Spreadsheet dated 1/23/24, showed regular/NAS (no added salt) diet, CCHO/ NAS (consistent carbohydrate) diet and liberal house renal diet included a serving mixed green salad. Review of the menu list dated 1/23/24, showed mixed green salad with dressing was a combination of fresh salad greens and sliced cucumbers served with dressing. Review of the recipe of the mixed green salad showed cucumbers as one of the ingredients. On 1/23/24 at 1220 hours, during the dining observation, Resident 9 was observed in her room with her lunch tray in front of her. The lunch tray included a bowl of salad; however, there were no slices of cucumbers in the salad. When asked about her salad and if she liked it with cucumbers, Resident 9 asked why she did not get cucumbers in her salad. On 1/23/24 at 1226 hours, an inspection of the satellite kitchen was conducted with the Culinary Director. The Culinary Director verified there were no cucumber slices on the mixed green salad served to the residents. The Culinary Director stated the food served were from the main kitchen, and the kitchen staff might have forgotten to add the cucumber slices. 2. On 1/24/24 at 1124 hours, during the trayline observation, a random inspection was conducted on the lunch trays in the tray cart ready to be served to the residents. Review of the menu ticket for Resident 30 showed to serve apple juice. Inspection of the lunch tray for Resident 30 did not show an apple juice was included. Dietary 1 verified the above findings.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

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 document review, the facility failed to ensure the food preferences were honored for one of 13 final sampled residents (Resident 9). * Resident 329's tray card showed the resident preferred chef salad and cranberry juice. However, this was not served to the resident. This had the potential to negatively impact the resident's well-being. Findings: On 1/23/24 at 1230 hours, during the dining observation, Resident 329 was observed with a mixed green salad, ravioli with cream sauce, and steamed spinach on her tray. Resident 329 stated she preferred chef salad and a cranberry juice as per tray card. On 1/23/24 at 1235 hours, Dietary Aide 1 verified Resident 329 was not served chef salad and cranberry juice as per the resident's tray card. Medical record review for Resident 9 was initiated on 1/23/24. Resident 329 was admitted to the facility on [DATE]. Review of Resident 9's Selection Sheet dated 1/25/24, showed Resident 329's preferred cranberry juice and chef salad. Review of Resident 9's [NAME] 101: Dietary Interview Pre-Screen - V2 dated 1/22/24, showed Resident 329's beverage preferences included cranberry juice and meal preferences for lunch included chef salad. On 1/23/24 at 1236 hours, a concurrent interview and medical record review was conducted with the Culinary Director. The Culinary Director stated the dietary staff should have followed the resident's preferences as stated in the tray card.

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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Based on observation, interview, and facility P&P review, the facility failed to follow their policy to ensure foods brought into the facility for residents by visitors were properly stored and safely consumed. * The facility failed to ensure the nursing staff were trained on properly labeling the food items brought in by the visitors for the residents. This failure had the potential for unsafe food handling. Findings: Review of the facility's P&P titled Food Brought in by Family dated 8/27/21, showed the following: - Family members and visitors are requested to inform nursing staff of their desire to bring food into the facility; - 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 they can understand; and - All personnel involved in preparing, handling, serving or assisting the resident with meals or snacks will be trained in safe food handling practices. On 1/23/24 at 0834 hours, an inspection of the refrigerator used for the residents' food brought in from the visitors, and concurrent interview was conducted with the IP/DSD. Several food items were observed not labeled with the resident's name, room and date received. The IP/DSD verified the findings. On 1/25/24 at 1415 hours, an interview was conducted with the IP/DSD. When asked if the nursing staff had been educated or trained on the safe storage and handling of resident foods brought in by the visitors, the IP/DSD stated she had not provided any staff training regarding safe storage and handling of the foods brought in for the residents by the visitors.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility P&P, the facility failed to ensure the complete and accurate medical records for six of 13 final sampled residents (Residents 16, 19, 24, 25, 330, and 430) and one nonsampled resident (Resident 24). *Resident 24's insulin was documented incorrectly as being administered in their axilla for 13 instances. *Resident 16's insulin was documented incorrectly as being administered in their axilla for seven instances. In addition, Resident 16's Care Conference assessment was not completed timely. *Resident 25's insulin was documented incorrectly as being administered in their axilla for three instances. *Resident 19's insulin was documented incorrectly as being administered in their axilla for two instances. In addition, Resident 19's Care Conference assessment was not completed timely. *Resident 330's insulin was documented incorrectly as being administered in their axilla for one instance. *Resident 429's and 430's Care Conference assessments were incomplete. * Resident 330's Care Conference assessment was not completed timely. These failures had the potential for inaccurate and incomplete medical records. Findings: 1. Medical record review for Resident 24 was initiated on 1/25/24. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24's MAR for January 2024 showed the following injections of Humalog KwikPen insulin were administered subcutaneously: -On 1/1/24 at 1630 hours, 10 units of insulin. -On 1/1/24 at 2100 hours, 10 units of insulin. -On 1/2/24 at 1630 hours, 10 units of insulin. -On 1/2/24 at 2100 hours, 10 units of insulin. -On 1/3/24 at 2100 hours, 6 units of insulin. -On 1/5/24 at 1130 hours, 10 units of insulin. -On 1/5/24 at 1630 hours, 8 units of insulin. -On 1/6/24 at 1630 hours, 15 units of insulin. -On 1/6/24 at 2100 hours, 6 units of insulin. -On 1/12/24 at 1630 hours, 8 units of insulin. -On 1/14/24 at 1630 hours, 10 units of insulin. -On 1/15/24 at 0630 hours, 6 units of insulin. -On 1/18/24 at 1630 hours, 6 units of insulin. Review of Resident 24's Location of Administration Report for January 2024 showed the above 13 doses were administered to the resident's axilla. On 1/25/24 at 1059 hours, an interview was conducted with Resident 24. Resident 24 stated they never received their insulin in their axilla. The resident stated the nursing staff always injected their insulin into the back of their upper arms or abdomen. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 24's Medication Administration Record and Location of Administration Report for January 2024 and verified the insulin was incorrectly documented as administered to the resident's axilla for 13 doses. 2. Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Medication Administration Record for January 2024, showed the following injections of Humulin R insulin were administered subcutaneously: -On 1/1/24 at 2100 hours, 6 units of insulin. -On 1/3/24 at 2100 hours, 6 units of insulin. -On 1/14/24 at 0630 hours, 6 units of insulin. -On 1/14/24 at 1630 hours, 6 units of insulin. -On 1/14/24 at 2100 hours, 6 units of insulin. -On 1/15/24 at 0630 hours, 6 units of insulin. -On 1/18/24 at 1630 hours, 6 units of insulin. Review of Resident 16's Location of Administration Report for January 2024, showed the above seven doses were administered to the resident's axilla. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 16's Medication Administration Record and Location of Administration Report for January 2024, and verified the insulin was incorrectly documented as administered to the resident's axilla for seven doses. 3. Medical record review for Resident 25 was initiated on 1/25/24. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's Medication Administration Record for January 2024, showed on 1/12/24 at 2100 hours, Insulin Glargine 20 units subcutaneously was administered. Review of Resident 25's Medication Administration Record for January 2024, showed the following injections of Humulin R insulin were administered subcutaneously: -On 1/7/24 at 2100 hours, 6 units of insulin. -On 1/15/24 at 2100 hours, 6 units of insulin. Review of Resident 25's Location of Administration Report for January 2024, showed the above three insulin doses were administered to the resident's axilla. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 25's Medication Administration Record and Location of Administration Report for January 2024, and verified the insulin was incorrectly documented as administered to the resident's axilla for three instances. 4. Medical record review for Resident 19 was initiated on 1/23/24. Resident 19 was initially admitted to the facility on [DATE]. Review of Resident 19's Medication Administration Record for January 2024, showed the following injections of Insulin Regular Human were administered subcutaneously: -On 1/3/24 at 1630 hours, 8 units. -On 1/5 /24 at 1630 hours, 6 units. Review of Resident 19's Location of Administration Report for January 2024, showed the above two doses were administered to the resident's axilla. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 19's Medication Administration Record and Location of Administration Report for January 2024 and verified the insulin was incorrectly documented as administered to the resident's axilla for two doses. 5. Medical record review for Resident 330 was initiated on 1/25/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's Medication Administration Record for January 2024, showed on 1/15/24 at 1630 hours, 6 units of Humalog KwikPen insulin were administered subcutaneously. Review of Resident 330's Location of Administration Report for January 2024, showed the above dose was administered to the resident's axilla. On 1/25/24 at 1320 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated subcutaneous injections were to be administered into the fatty posterior of the arm, abdomen, or legs, and not the axilla. RN 1 reviewed Resident 330's Medication Administration Record and Location of Administration Report for January 2024 and verified the insulin was incorrectly documented as administered to the resident's axilla for one dose. 6. Medical record review for Resident 19 was initiated on 1/23/24. Resident 19 was initially admitted to the facility on [DATE]. Review of Resident 19's Generations Care Conference - V 3 dated 12/10/23, showed Section A was completed on 1/18/24, and Sections B, C and D were incomplete. On 1/24/24 at 1015 hours, an interview and concurrent medical record review were conducted with the SSD. The SSD reviewed Resident 19's Generations Care Conference - V 3 dated 12/10/23, and verified it was incomplete. On 1/24/24 at 1420 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated the Care Conference assessments were available for staff to document in once the assessment document was created, and the care conference was held within 72 hours after admission. Review of the assessment screen showed Sections B, C and D were completed on 1/24/24. The DON reviewed Resident 19's Generations Care Conference - V 3 dated 12/10/23, and verified she had just competed Sections B, C, and D that day, and they were not completed timely. 7. Medical record review for Resident 16 was initiated on 1/23/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Generations Care Conference - V 3 dated 12/4/23, showed Sections A, B, C, and D were incomplete. On 1/24/24 at 1420 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated the Care Conference assessments were available for staff to document in once the assessment document was created, and the care conference was held within 72 hours after admission. Review of the assessment screen showed Sections A, B, C and D were completed on 1/24/24. The DON reviewed Resident 16's Generations Care Conference - V 3 dated 12/4/23, and verified she had just competed the sections that day, and they were not completed timely. 8. Medical record review for Resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Review of Resident 429's Generations Care Conference - V 3 dated 1/17/24, showed Sections A, B, C and D were incomplete. On 1/24/24 at 1420 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated the Care Conference assessments were available for staff to document in once the assessment document was created, and the care conference was held within 72 hours after admission. The DON reviewed Resident 429's Generations Care Conference - V 3 dated 1/17/24, and verified the documentation was not completed timely. 9. Medical record review for Resident 430 was initiated on 1/23/24. Resident 430 was admitted to the facility on [DATE]. Review of Resident 430's Generations Care Conference - V 3 dated 1/17/24, showed Sections A, B, C and D were incomplete. On 1/24/24 at 1420 hours, an interview and concurrent medical record review were conducted with the DON. The DON stated the Care Conference assessments were available for staff to document in once the assessment document was created, and the care conference was held within 72 hours after admission. The DON reviewed Resident 430's Generations Care Conference - V 3 dated 1/17/24, and verified the documentation was not completed timely. 10. On 1/23/24 at 0924 hours, during the initial tour of the facility, an interview was conducted with Resident 330. Resident 330 stated she wanted to ask the social worker about her discharge planning. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was readmitted to the facility on [DATE]. Review of Resident 330's History and Physical examination dated 1/15/24, showed Resident 330 did not have the capacity to understand and make decisions. Review of Resident 330's Generations Care Conference - V3 dated 1/13/24, showed the admission care conference was conducted on 1/16/24 at 1100 hours. Review of the care conference form showed the sections for medication/ assistive devices, nursing, and social services were blank. Further review of the care conference form showed only the dietary and vitality personnel were signed, and there were no signatures from the nursing, therapy, social services, resident, and her responsible party. On 1/24/24 at 0953 hours, an interview and concurrent medical record review for Resident 330 was conducted with the SSD. When asked about Resident 330's discharge planning, the SSD stated the discharge planning was discussed during the care conference conducted with the resident, her responsible party, and the department heads. The SSD stated the care conference was usually conducted within five days upon admission, unless the resident or responsible party asked to do it after that. The SSD verified the care conference form for Resident 330 was incomplete and should have been completed within that timeframe.

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 and facility document review, the facility failed to implement their POC dated 2/6/23. There was no documentation to show the facility was monitoring the results of audits to the QAPI committee meetings to identify if they had achieved compliance threshold of 100% for repeated deficient practice cited at F695 in accordance with their POC for recertification survey dated 2/6/23. This failure had the potential to affect the quality of care for all the residents in the facility. Findings: On 1/26/24 at 1304 hours, an interview and concurrent facility document review was conducted with the Administrator and DON. Review of the POC submitted by the facility to the CDPH, L&C Program for the recertification survey completed on 2/6/23, showed the deficient practice cited at F695 related to oxygen order not indicating whether the oxygen should be continuous or as needed. The POC included the following: * Medical Records, RN Supervisor, the DON and/or designee will monitor daily all oxygen administration orders. * Findings will be discussed and reviewed daily during stand-up meeting and at the facility's monthly QAPI meeting. * Compliance will be monitored and discussed during daily clinical meeting and at the QAPI meetings with an expected compliance threshold of 100%. The Administrator verified the above findings and stated every three months, the QAPI meetings were conducted to address the POC compliance. The Administrator could not provide documentation on how the missing reports on the audits for the deficient practice cited at F695 was addressed. The Administrator stated the facility was not in 100% compliance so they would still be addressing this issue in their quarterly QAPI meetings.

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** 9. Review of the facility's P&P titled Catheter Care, Urinary revised 8/2022 showed the facility shall ensure prevention of urinary catheter associated complications, including urinary tract infections, provide resident's care plan to assess for any special needs of the resident, and ensure the drainage bag are kept off the floor. Medical record review for Resident 679 was initiated on 1/23/24. Resident 679 was admitted to the facility on [DATE], and readmitted on [DATE]. On 1/23/24 at 1238 hours, Resident 679 was observed sitting on his wheelchair, eating his lunch, with the TV on. Resident 679's indwelling urinary drainage bag was observed laying on the floor. On 1/23/24 at 1240 hours, an observation and concurrent interview was conducted with LVN 3. LVN 3 verified the indwelling urinary drainage bag was laying on the floor and should be kept off the floor. 7. During initial tour of the facility on 1/23/24 at 1159 hours, an observation and concurrent interview was done with LVN 1 and CNA 2. The bedpans and basins used by Residents 630 and 633 were observed in the residents' bathroom without a label. LVN 1 and CNA 2 verified the bedpans and basins were not labeled for Residents 630 and 633. LVN 1 and CNA 2 stated for rooms with two residents, the bedpans and basins used by residents in the room should have been labeled with their names. When asked who was responsible to label the equipment, LVN 1 stated either the licensed nurse or the CNA was to label the equipment during admission. Medical record review for Resident 630 was initiated on 1/23/24. Resident 630 was admitted to the facility on [DATE]. Medical record review for Resident 633 was initiated on 1/23/24. Resident 633 was admitted to the facility on [DATE]. On 1/24/24 at 1015 hours, an interview was conducted with the IP. The IP stated for rooms with two residents, the bedpans and basins used by the residents should have been labeled with the residents' names to prevent cross-contamination between the residents. The IP stated the expectation was for either the licensed nurse or CNA to label the bedpans and basins during the residents' admissions. The IP was informed and acknowledged the above findings. 5. Review of the facility's P&P titled Clostridium Difficile revised 10/2018 showed steps toward prevention and early intervention include frequent hand washing with soap and water by staff and residents. When caring for resident with Clostridioides Difficile Infection (CDI), staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to alcohol based hand rub (ABHR) for mechanical removal of the clostridium difficile spores. On 1/23/24 at 0833 hours, an IV medication administration observation was conducted with RN 1. RN 1 used required PPE prior entering Resident 429's room who was on contact isolation. RN 1 programmed the IV pump in resident's room, cleansed Resident 429's access site, and administered the IV medication. RN 1 removed PPE after administration of medication by the Resident 429's doorway and cleansed her hands with alcohol sanitizer. RN 1 then proceeded to prepare IV medication for another resident (Resident 630). On 1/23/24 at 1530 hours, an interview was conducted with RN 1. RN 1 stated she did not wash her hands with soap and water; however, used an alcohol-based sanitizer to clean her hands prior to the preparation of Resident 630's medications. On 1/25/24 at 1503 hours, an interview was conducted with the DON. The DON stated the staff were expected to wash hands with soap and water after caring for a resident who was infected with C. Difficile. 6. Review of the facility's P&P titled Clostridium Difficile revised 10/2018, showed environmental cleaning in the rooms of resident with Clostridioides Difficile Infection (CDI) is done with a disinfecting agent recommended for Clostridium Difficile (household bleach and water solution or an Environmental Protection Agency (EPA) registered germicidal agent effective against Clostridium Difficile spores. On 1/24/24 at 0859 hours, RN 1 was observed cleaning the IV pole with alcohol sani-wipes from Resident 429 who was on contact isolation for c. difficile because the IV medication was discontinued. RN 1 put plastic over the IV pole, then stated this was ready for the next resident to use. On 01/24/24 at 0903 hours, an interview was conducted with RN 1. RN 1 stated she was not aware the alcohol sani wipes was not sufficient to clean the euipment. On 1/25/23 at 1503 hours, an interview was conducted with the DON. The DON stated the staff were expected to know the equipment from a resident infected with CDI should be cleaned with bleach. The DON was made aware of the above findings and acknowledged the findings. Based on interview, observation, facility document review, and facility P&P, the facility failed to ensure an appropriate infection control practices for one of 13 final sampled residents (Resident 429), two nonsampled residents (Residents 630 and 633) and in the facility laundry service area. * The facility failed to follow appropriate transmission-based precautions for Resident 429. * The facility failed to ensure the staff implemented handwashing with soap and water after caring for Resident 429 who was on contact isolation for C. Difficile to care for another resident. * The facility failed to ensure equipment used for Resident 429 who was infected with C. Difficle were appropriately disinfected. * The bedpans and basins for Residents 630 and 633 in a double bed room were not labelled. * The facility failed to ensure Resident 679's urinary drainage bag was kept off the floor. * The facility failed to ensure the employee's personal belongings were not in the clean linen folding area. These failures had the potential for spread of infections. Findings: 1. Review of the facility's P&P titled Management of C. Difficile Infections dated 6/25/23, showed Clostridioides difficile (C. diff) is a bacterium that causes diarrhea and colitis (inflammation of the colon). It is spread by direct contact with contaminated objects or the hands of persons who have touched a contaminated object. The P&P also showed contact precautions shall be implemented, in addition to the following: -All staff are to wear gowns and gloves upon entry into the resident's room and while providing cares. -Hand hygiene shall be performed by handwashing with soap and water. -Thoroughly clean and disinfect reusable equipment with sporicidal disinfectant (agent that destroys bacterial and fungal spores). Review of the CDC's, Clean Hands Count for Healthcare Providers Factsheet undated, showed C. diff spores are not killed by alcohol-based hand sanitizer and to wash your hands with soap and water after removing gloves. Review of the CDC's, Prevent the Spread of C. diff, reviewed 7/20/21, showed C. diff spores have a protective coating allowing them to live for months or sometimes years on surfaces. Medical record review for resident 429 was initiated on 1/23/24. Resident 429 was admitted to the facility on [DATE]. Review of Resident 429's Order Summary Report dated 1/24/24, showed a physician's order dated 1/17/24, for contact isolation for C. diff. a. On 1/23/24 at 0831 hours, Resident 429 was observed in bed. Outside the resident's doorway, isolation signage was posted next to the door above the plastic drawers. On top of the cart, one container of alcohol based Super Sani-Cloth wipes, one container of Sani-Cloth Bleach wipes, and one pump bottle of alcohol-based hand sanitizer were observed. Isolation gowns were in the bottom drawer. On 1/23/24 at 0910 hours, the MDS/RAI Coordinator was observed in Resident 429's wearing a procedure mask and gloves. No isolation gown was observed in use. The MDS/RAI Coordinator was observed touching Resident 429's bed controls on the foot of their bed. The MDS/RAI Coordinator removed her gloves and used alcohol-based hand rub for hand hygiene. The MDS/RAI Coordinator proceeded to the nurses' station, picked up papers off the copy machine, and walked down another hallway to go speak to a nurse. On 1/23/24 at 0913 hours, an interview was conducted with the MDS/RAI Coordinator. The MDS/RAI Coordinator stated she was doing her routine daily rounds, and greeted Resident 429 and used the resident's bed controls to adjust their bed. The MDS/RAI Coordinator stated they saw the isolation signage at the resident's doorway, and that's why they were wearing a procedure mask and gloves. The MDS/RAI Coordinator verified they used alcohol-based hand rub (ABHR) for hand hygiene and was not wearing an isolation gown while in the resident's room. When asked what Resident 429 was in isolation for, the MDS/RAI Coordinator stated she would have to check. When asked what isolation precautions were needed for C. diff, the MDS/RAI Coordinator stated a gown was also required. When asked if she washed her hands when leaving the resident's room, the MDS/RAI Coordinator stated they did not have to because they used ABHR, and was not aware handwashing with soap and water were required for C. diff isolation precautions. On 1/23/24 at 0917 hours, an interview was conducted with the IP/DSD. The IP/DSD stated for C. diff, the staff must wear a gown and gloves while in the room. The IP/DSD was not aware the ABHR were not effective for use with C. diff. On 1/23/24 at 0922 hours, and interview was conducted with the Administrator. The Administrator stated for C. diff, the staff must perform hand washing as ABHR was not effective against C. diff spores. b. On 1/23/24 at 1144 hours Resident 429's call light indicator was observed being on above the door. CNA 1 donned a gown, gloves, and procedure mask and entered Resident 429's room. The indicator light above the resident's doorway was turned off. CNA 1 was heard talking briefly to the resident and was observed removing the gown and gloves, used ABHR, and left the room. CNA 1 stated they knew they were supposed to wash their hands for C. diff, but they did not touch the resident and just turned off the call light. c. On 1/23/24 at 1216 hours, the Activity Director was observed in Resident 429's room wearing an isolation gown, gloves, and procedure mask while talking to the resident. The Activity Director removed the PPE, and used ABHR, and left the resident's room. The Activity Director verified they used ABHR and did not wash their hands when leaving the room. The Activity Director stated they brought the resident the Daily Chronicle (a single sheet paper printout) and turned on the resident's TV. The Activity Director stated they usually brought the resident crossword puzzles and magazine to read. Sometimes, they would discard the items when the resident was done with them, or she would wipe down the magazines with the alcohol-based wipes. d. On 1/24/24 at 1115 hours, Family Member 1 was observed in Resident 429's room. Family Member 1 was wearing a procedure mask, but was not wearing an isolation gown or gloves. Family Member 1 moved the resident's bedside tray table, removed a blanket from Resident 429's bed, and placed a blanket just brought in over the resident. On 1/24/24 at 1132 hours, LVN 1 was observed in Resident 429's doorway and asked Family Member 1 to please wear the gown and gloves and to wash their hands when they left. Family Member 1 went to the doorway and put on an isolation gown and gloves. On 1/24/24 at 1342 hours, an interview was conducted with Family Member 1. Family Member 1 stated they were aware Resident 429 was in isolation at the hospital, but today was the first time anyone at the facility asked them to wear a gown and gloves. Family Member 1 stated they visited Resident 429 daily since their admission. 8. Review of facility's P&P titled Laundry Bedding dated 9/1/22, showed the clean linen is protected from dust/ soiling during transport and storage to ensure cleanliness. Review of the facility's P&P titled Personal Cell Phones dated 9/2020 showed employees may carry cell phones on their person while at work, unless explicitly mandated otherwise for any reason by their supervisor. Cell phone may be used by employees while on a scheduled break areas only. On 1/26/24 at 0827 hours, an observation of the laundry area and concurrent interview was conducted with the Laundry Aide and Plant Operations Director. The following was observed: a. A cellphone, a container of petroleum jelly, a bag, a purple sweater, a face mask, a faceshield, and binders were observed on the folding table in the clean area. The binders were observed touching the resident towels. b. The laundry P&P were not posted or available in the laundry area. The Laundry Aide and the Plant Operations Director verified the findings. The Laundry Aide acknowledged she placed her personal items on the clean folding area. The Laundry Aide stated she was not informed she could not store her personal items on the clean folding area. When asked about the laundry P&P, the Laundry Aide and the Plant Ops Director could not locate the P&P, and the Plant Ops Director stated he would have to print it out.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Infection Control 12-Antibiotic Stewardship Surveillance dated 11/15/22 showed that all resident antibiotic regimens will be documented via the facility approved antibiotic surveillance tracking method. Information will include: a) resident name; b) unit number; c) date symptoms appeared; d) name of antibiotic e)start date of anitibiotic; f) pathogen identified g) site of infection h) date of culture i) stop date; j) total days of therapy; k) outcome; and l) adverse events. Medical record review for Resident 13 was initiated on 1/24/24 at 0834 hours. Resident 13 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 13 with diagnosis including UTI, not specified. Review of the Order Summary Report showed a physician's order dated 12/24/23, for Methenamine Hippurate oral tablet 1 gm one tablet by mouth one time a day for UTI prophylaxis. On 01/24/24 at 1114 hours conducted interview and concurrent record review with RN 1. RN 1 verified there was no clarification made with the phycian by the licensed nurses regarding the stop date of the Methenamine Hippurate ordered on 12/24/23, for UTI prophylaxis for Resident 13. Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to monitor and address the use of antibiotic to identify if the resident's condition did or did not meet the McGeer's criteria (a set of specific definitions to identify true infections in long term nursing facilities) for four of 12 nonsampled residents (Residents 11, 13, 634, and 635). The facility failed to complete the criteria for indication of antibiotic use for Residents 11, 13, 634, and 635. In addtion, Resident 13's antibiotic order was not clarified with the physician regarding the stop date. These failures had the potential to negatively impact the residents' well-being. Findings: Review of the facility's P&P titled Infection Control 10-Antibiotic Stewardship dated 7/28/23, showed Infection Preventionist to utilize expertise and data to inform strategies to improve antibiotic use to include tracking of antibiotics starts, monitoring adherence to evidence-based published criteria during evaluation and management of treated infections, and reviewing antibiotic resistance patterns in the facility to understand which infections are caused by resistant organisms. Facility uses CDC's NHSN Surveillance Definitions, updated McGreer criteria, or other surveillance tool to define infections. Loeb Minimum Criteria may be used to determine whether to treat infection with antibiotics. All prescriptions for antibiotics shall specify dose, duration, and indication for use. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. Antibiotic orders from consulting, specialty, or emergency providers should be reviewed for appropriateness. New or changed orders based on antibiotic timeout recommendations will be obtained from the practitioner. Review of the facility's P&P titled Infection Control 12-Antibiotic Stewardship Surveillance dated 11/15/22, showed identifying an Infection Preventionist who would review antibiotic utilization as part of the antibiotic stewardship program identifying specific situations not consistent with appropriate use of antibiotics. At review conclusion, provider will be notified of review findings as needed. Review of the facility document was initiated on 1/25/24. The Infection Control Binder containing Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) failed to show the criteria to determine for true UTI was completed for Residents 11, 13, 634, and 635. Resident 13's antibiotic order did not show a stop date. 1. Medical record review for Resident 11 was initiated on 1/25/24. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's Order Summary Report showed a physician's order dated 12/19/23, for Zosyn Intravenous Solution 3.375 mg intravenously every eight hours for UTI until 12/25/23 at 2359 hours. Review of Resident's 11 Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) dated 12/20/23, showed the criteria checklist to determine if the resident had a true UTI was not completed. 2. Medical record review for Resident 13 was initiated on 1/25/24. Resident 13 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 13's Order Summary Report showed the following: a. A physician's order dated 12/18/23, for Cefpodoxime Proxetil oral tablet (antibiotic) give one tablet by mouth every 12 hours for UTI until 12/23/23 at 2359 hours. b. A physician's order dated 12/18/23, for Methenamine Hippurate oral tablet (used to prevent or control returning urinary tract infections caused by certain bacteria) 1 gm one tablet by mouth one time a day for UTI prophylaxis. Review of Resident 13's Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) dated 12/18/23, showed the criteria checklist to determine if the resident's infection was true infection or true UTI was not completed. 3. Medical record review for Resident 634 was initiated on 1/25/24. Resident 634 was admitted to the facility on [DATE]. Review of Resident 634's Order Summary Report showed a physician's order dated 12/13/23, for Bactrim DS oral tablet 800-160 mg one tablet by mouth one time a day for sepsis until 12/15/23 at 2359 hours. Review of Resident 634's Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) dated 12/12/23, showed the criteria checlist to determine if the resident's infection was true infection or true UTI was not completed. 4. Medical record review for Resident 635 was initiated on 1/25/24. Resident 635 was admitted to the facility on [DATE]. Review of Resident 635's Order Summary Report showed a physician's order dated 12/1823, for macrobid Oral Capsule (antibiotic) 100 mg one capsule by mouth two times a day for UTI until 12/18/23 at 2359 hours, and was discontinued on 12/19/23. Review of Resident 634's Surveillance Data Collection-Infection Control (Urinary Tract Infections for Resident without Indwelling Catheter) dated 12/12/23, showed the criteria checklist to determine if the resident's infection was a true infection or true UTI was not completed. On 1/25/24 at 1321 hours, an interview and concurrent medical record review was conducted with the IP. The IP stated the criteria to determine for true UTI or true infection should have been completed for the indication of antibiotics use and the antibiotic order should have a stop date. The IP further stated the criteria findings should have been communicated with the physician, however, it was not completed. The IP verified 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** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the residents' bed were inspected, entrapment assessments were completed, and with the record of the bed inspection when identifying areas of possible entrapment with the use of bed rails for four of 13 final sampled residents (Residents 9, 25, 330, and 379). These failures 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 Bed Safety dated 9/23/22, showed the inspection of all beds and related equipment including the frame, mattress, assistive devices, and bed accessories. The assistive devices were properly installed using the manufacturer instructions and other pertinent safety guidance to ensure proper fit. There should be an assessment of the resident using assistive device for bed mobility. If side rails were used, the maintenance staff will inspect the rails monthly and as needed to ensure the rails are in proper working order and placed appropriately in bed. 1. On 1/23/24 at 0908 hours, and 1/24/24 at 0858 hours, Resident 25 was observed in bed with the left upper side rails was elevated. Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted to the facility on [DATE]. Cross reference to F700, example #1. 2. On 1/24/24 at 0836 hours and 1/25/24 at 0846 hours, an observation and concurrent interview with Resident 379. Resident 379 was observed in bed with the upper side rails elevated. Resident 379 stated he was not able to use the side rail because he was in pain when he moves in bed. Medical record review for Resident 379 was initiated on 1/24/24. Resident 379 was admitted to the facility on [DATE]. On 1/25/24 at 1112 hours, an interview for Resident 25 and 379 was conducted with the Plant Operation Director. The Plant Operation Director stated he was responsible for inspecting, fixing, and placing the side rails in bed weekly and as needed. The Plant Operation Director was asked if the entrapment assessment was done for the bed rails. The Plant Operation Director stated the entrapment assessment was not done because the enabler was not considered a bed rails. When asked if there was any record log for the bed inspection, the Plant Operation Director verified there was no record log of bed inspection and entrapment assessment. On 1/24/24 at 1609 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. Cross reference to F700, example #2. 3. On 1/23/24 at 0924 hours, on 1/24/24 at 1044 hours, and 1/25/24 at 0945 hours, bilateral assist rails were observed on Resident 330's bed. On 1/25/24 at 0932 hours, an interview for Resident 330 was conducted with CNA 5. When asked about Resident 330's use of the assist rails, CNA 5 stated Resident 330 used the assist rails during turning and repositioning. On 1/25/24 at 0945 hours, Resident 330 was observed sitting in the wheelchair in her room. Bilateral assist rails were observed elevated. When asked about the bilateral assist rails, Resident 330 stated she used the assist rails when for turning and repositioning while in bed. Medical record review for Resident 330 was initiated on 1/23/24. Resident 330 was admitted to the facility on [DATE]. Review of Resident 330's medical record did not show an entrapment assessment and bed inspection. Cross reference to F700, example #3. 4. On 1/23/24 at 0959 hours, on 1/24/24 at 1338 hours, and 1/25/24 at 0905 hours, bilateral assist rails were observed on Resident 9's bed. On 1/24/24 at 1338 hours, Resident 9 was observed sitting in the wheelchair in her room. Bilateral assist rails were observed elevated. When asked about the bilateral assist rails, Resident 9 stated she used the assist rails when getting out of bed. On 1/25/24 at 0931 hours, an interview for Resident 9 was conducted with CNA 5. When asked about Resident 9's use of the assist rails, CNA 5 stated Resident 9 used the assist rails when getting up from bed, and during turning and repositioning. Medical record review for Resident 9 was initiated on 1/23/24. Resident 9 was readmitted to the facility on [DATE]. Review of Resident 9's medical record did not show an entrapment assessment and bed inspection. On 1/25/24 at 1112 hours, an interview for Residents 9 and 330 was conducted with the Plant Operation Director. The Plant Operation Director stated he was responsible bed inspection including maintaining, inspecting, and installing the assist rails. The Plant Operations stated the bed inspections were done weekly. When asked if he had done the entrapment assessment for the assist rails, the Plant Operations Director stated he did not do any entrapment assessment as the assist rails were enablers and not bed rails. When asked if he has any documentation of the weekly bed inspection, the Plant Operations Director verified there were no record of the weekly bed inspection conducted. Cross reference to F700, example #4.

CONCERN (D)

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

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain the effective pest control program to prevent the presence of gnats in the main kitchen and the satellite kitchen. This failure had the potential to lead to food-borne illnesses (illnesses caused by food contaminated with bacteria, viruses, parasites or toxins) to the residents who eat food prepared in the kitchen. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. According to the USDA Food Code 2022, 6-501.111 Controlling Pests, showed insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. Review of the facility's P&P titled Pest Control revised May 2008 showed the facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. On 1/24/24 at 0832 hours, an inspection of the main kitchen and concurrent interview was conducted with the Culinary Director. Gnats were observed in a bag of bread and in the food preparation area in the main kitchen. The Culinary Director verified the findings. The Culinary Director stated they had a fly trap in the main kitchen. On 1/24/24 at 1339 hours, an interview was conducted with the Plant Operations Director. When asked about the gnats in the kitchen, the Plant Operations Director stated the pest prevention company came last month, to which he showed the service information. Review of the service information conducted by the pest control company dated 12/8/23, showed there were no pest activity during the pest control company inspection to the facility. On 1/24/24 at 1602 hours, an inspection of the satellite kitchen and concurrent interview was conducted with the CDM. Gnats were observed in the food preparation area in the main kitchen. The CDM verified the 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, 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 proper hand hygiene were practiced by the dietary staff in the satellite kitchen. * The facility failed to ensure hair and beard restraint were worn by a non-dietary personnel inside the main kitchen. * The facility failed to ensure the meat thawing in the refrigerator in the main kitchen was labeled with the use-by date, and the date when the meat was pulled from the freezer. * The facility failed to ensure the proper labeling and dating of the food items in the main kitchen and satellite kitchen. * The facility failed to ensure the proper labeling and dating of the foods in refrigerator was in placed for the residents' food brought in by visitors. In addition, the facility failed to ensure the food items were discarded after a resident has been discharged . * The facility failed to ensure the expired food items in the main kitchen were discarded. * The facility failed to ensure the plates, storage bins for bowls and plates, and heated plate dispenser were clean. * The facility failed to ensure the employee personal belongings were not stored in the main kitchen food preparation area. * The facility failed to air dry the plate bases before using in the trayline service. * The facility failed to ensure the quaternary sanitizing strips to check the sanitizing solution for the manual ware washing and sanitization buckets were not expired. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared from the kitchen. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. 1. According to the USDA Food Code 2022, 2-301, When to Wash, showed food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment, and utensils, and unwrapped single-service and single use articles; after handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; before donning gloves to initiate a task that involves working with food; and after engaging in other activities that contaminate the hands. Review of the facility's P&P titled Personal Hygiene/ Safety/ Food Handling/ Infection Control revised 5/18/23, under Clean Hand, Fingernails and Gloves section, showed hands must always be washed prior to beginning work. On 1/23/24 at 0810 hours, during the initial inspection of the satellite kitchen, the kitchen sink was observed not working. A brown stain was observed from the controls to the basin of the kitchen sink. Two dietary staff in the satellite kitchen were observed wearing disposable food prep gloves and preparing breakfast trays. Dietary Aide 1 verified the kitchen sink in the satellite kitchen was not working. Dietary Aide 1 stated the kitchen sink was not working in the morning so they had to use a hand sanitizer and then wear the disposable food prep gloves. Cross reference to F908, example # 2. 2. According to the USDA Food Code 2022 Section 2-402.11 Hair Restraints, Effectiveness, showed food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. Review of the facility's P&P titled Personal Hygiene/ Safety/Food Handling/ Infection Control revised 5/18/23, under Head Covering Worn section, showed the following: -Wear a clean hat or other hair restraint. Hair must be appropriately restrained or completely covered; -Head covering must be clean; -Beards, mustaches or any body hair that maybe exposed must be covered. On 1/24/24 at 1120 hours, a technician was observed in the main kitchen. The technician was not wearing a hair and beard restraints. The Culinary Director verified the findings. 3. According to Food Code 2022, 3-501.13, Thawing, showed freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/ or produce toxins. Review of the facility's P&P titled Refrigerated Storage Chart, under the Meat, Fish, and Poultry - Fresh section revised 12/28/20, showed the recommended time was at 35 to 41 degrees F or less for beef, lamb, pork, and veal chops, steaks or roasts is two to four days, while ground meat or stew meat is one to two days. On 1/24/24 at 0832 hours, four packs of ground beef with a received date of 1/19/24, and four packs with a received date of 1/12/24, were observed in the walk-in refrigerator in the main kitchen. There was no date when the meats were pulled from the freezer. The Culinary Director verified the above findings. 4. Review of the facility's P&P titled Food Receiving and Storage dated 1/1/20, showed the foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). a. On 1/23/24 at 0810 hours, an initial satellite kitchen tour and concurrent interview was conducted with Dietary Aide 1. * The following food items were observed in Refrigerator 1: - Seven clear bowls of cut-up watermelon, cantaloupe and melon, and two Styrofoam bowls of cut-up peaches were observed on a tray. The bowls of fruits and/or the tray were not labeled with the use-by dates; - Three cups of orange juice, seven cups of apple juice, and fruit cups were observed on a tray. The cups and/ or the tray were not labeled with the use-by dates; and - A container of cut-up peaches was not labeled with the use-by date. * The following food items were observed in Refrigerator 2: -One opened gallon milk was not labeled with the opened date and use-by date; -One opened container of butterscotch pudding was not labeled with the opened date and use-by date; -One pitcher of iced tea was not labeled with the opened date and use-by date; -One opened container of salsa was not labeled with the opened date and use-by date; and -One opened container of prune juice concentrate not labeled with the opened date and use-by date; Dietary Aide 1 verified the above findings. Dietary Aide 1 stated she forgot to label the food items with the opened date. b. On 1/24/24 at 0832 hours, an inspection of the main kitchen and concurrent interview was conducted with the Culinary Director. The following food items were observed in the dry storage area without the label of opened date and use-by-date: - An opened bag of polenta - An opened bag of egg noodles - Two opened bags of spaghetti - An opened bag of tricolor rotini - Two opened bags of macaroni pasta - An opened bag of penne rigate pasta - An opened box of lasagna pasta - An opened bag of marshmallow - An opened bag of powdered sugar The Culinary Director verified the above findings. 5. Review of the facility's P&P titled Food Brought in by Family dated 8/27/21, showed the food brought by the family/ visitors for individual residents may not be shared with or distributed to other residents. The food brought by the family/ visitors that left for the resident to consume later will be labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. On 1/23/24 at 0834 hours, an inspection of the refrigerator used for residents' food brought in from visitors, and concurrent interview was conducted with the IP/DSD. The following food items were observed: - A fruit bowl was not labeled with resident name, room and date received. - An ice pop was labeled with resident name and room number. The IP/DSD stated the resident had already been discharged . - A can of green tea was not labeled with the resident name, room number, and date received. - A container of vanilla honey yogurt was not labeled with the resident name, room and date received. The IP/DSD verified the above findings. The IP/DSD stated the food items were supposed to be labeled with the resident name, room number and date when the food items were received. The IP/DSD stated if the food item was from the restaurant and/or from home, they were only supposed to keep the food for three days; but if the food items were store-bought, they could keep the food until consumed or expired, or give the food back or discard when the resident discharged . Cross reference to F813. 6. On 1/24/24 at 0832 hours, an inspection of the dry storage in the main kitchen, and concurrent interview was conducted with the Culinary Director. The following was observed: -A bag of chocolate chips was observed with a use-by date of 4/28/23; -A box of small white beans was observed with a use-by date of 11/15/23; and -A box of small white beans was observed with a use-by date of 4/10/22. The Culinary Director verified the above findings. 7. 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 2017, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 1/23/24 at 0818 hours, during the initial tour of the satellite kitchen and concurrent interview was conducted with Dietary Aide 1. The following was observed: -The heated plate dispenser was observed with plates inside. The heated plate dispenser was observed with a brownish stain on the inner panel; -Five plates on the heated plate dispenser were observed with food debris; -The storage bin for plates and bowls were observed with food debris; and -The lids of the storage bins for condiments, and cereals were dirty and dusty. Dietary Aide 1 verified the above findings. 8. Review of the facility's P&P titled Personal Hygiene/ Safety/ Food Handling/ Infection Control revised date 5/18/23, under the Designated Area for Employee Personal Belongings section showed the following: - An area in the Director of Food and Nutrition office or dry storage area may be designated as a separate employee personal belonging area with signage; and - Personal belongings, beverages and/ or food may be stored in the designated area. Review of facility's P&P titled Personal Cell Phones dated 9/2020 showed the employees may carry cell phones on their person while at work, unless explicitly mandated otherwise for any reason by their supervisor. Cell phone may be used by employees while on scheduled break areas only. a. On 1/24/24 at 0832 hours, an inspection of the main kitchen and concurrent interview was conducted with the Culinary Director. The following was observed: - A cellphone was observed on top of the sink inside the main kitchen; and - A pen was observed inside the storage bin for flour. The Culinary Director verified the above findings. b. On 1/24/24 at 1101 hours, during a follow-up inspection of the main kitchen, a cellphone and a phone charger were observed in the cereal food preparation area. Dietary Aide 3 verified the above findings. 9. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air- Drying Required, showed items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganism can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms. On 1/24/24 at 1120 hours, during the trayline observation, four insulated plate bases were observed stacked togethe, and ready to be used during the trayline service. The Culinary and CDM verified the above findings. 10. According to the USDA Food Code 2022, 4-301.12, Manual Ware Washing, the three- compartment requirement allows for the proper execution of the three-step manual ware washing procedure. If properly used, the three compartments reduce the chances of contaminating the sanitizing water and therefore diluting the strength and efficacy of the chemical sanitizer that may be used. Alternative manual ware washing equipment, allowed under certain circumstances and conditions, must provide for accomplishment of the same three steps: application of cleaners and the removal of soil, removal of any abrasive and removal or dilution of cleaning chemicals, and sanitization. Review of the manufacturer's Safety Information on pH Test Papers (undated) showed the pH test papers are marked with an expiration date and will perform as designed until that date as long as stored in a dry area, protected from sunlight. On 1/24/24 at 1403 hours, an observation and concurrent interview was conducted with Dietary Aide 1. When asked to check the sanitizer solution of the quaternary sanitizer bucket (red sanitizing bucket), Dietary Aide 1 was observed checking the concentration of the sanitizer using a piece of quaternary sanitizer strip. The quaternary sanitizer strip container had an expiration date of 2/1/22. Dietary Aide 1 verified the quaternary sanitizer strip container had expired. Cross reference to F908, example #1.

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, and facility document review, the facility failed to maintain the essential kitchen equipment in safe operating condition. * The facility failed to ensure the dish machine in the satellite kitchen was working. * The facility failed to ensure the sink in the main kitchen was not leaking. * The facility failed to ensure there was no ice buildup and brownish stain in the freezer of the refrigerator used to store residents' food brought in by the visitors. These failures had the potential for the equipment to not function in the way it was intended, which could cause food borne illnesses for the residents. Findings: Review of the facility's Diet Type Report dated 1/24/24, showed 30 of the 34 residents residing in the facility received foods prepared in the kitchen. According to USDA Food Code 2022, Section 4-501.11, Good Repair and Proper Adjustment, showed the proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. Review of the Dish Machine Temperature Log - Low Temp for January 2024, showed the instruction as follows: the dish machine temperatures and chemical levels must be monitored and recorded every meal period. Wash cycle must be between 110 to 120 degrees F. Chlorine levels must be between 50 to 100 ppm (parts per million), and quaternary levels must be between 180 to 200 ppm. Furthe review of the Dish Machine Temperature Log showed the wash temperatures were recorded as 121/124 for breakfast, lunch, and dinner every day from 1/1 to 1/23/24. 1. On 1/24/24 at 1403 hours, an observation of the dish machine and concurrent interview were conducted with Dietary Aide 1, with the CDM and the Plant Operations Director present. When asked to check the dish machine water temperature during the wash cycle, Dietary Aide 1 was observed checking the thermometer gauge which showed 100 degrees F. When asked to demonstrate how to check the sanitizing solution of the dishwasher, Dietary Aide 1 was initially observed using a pH strip and dipped the strip into the dish surface on the final rinse. The CDM stated Dietary Aide 1 used the wrong strip and should use the chlorine strip instead. Dietary Aide 1 was observed using the chlorine test strips and dipped the strip into the dish surface on the final rinse. The testing strip color did not change. Dietary Aide 1 repeated the steps, and the strip color still did not change, and the strip only read 10 ppm. The Plant Operations Director and CDM were observed checking the hoses connected to the bottles of detergent and sanitizer. The Plant Operations Director and CDM verified the dish machine was not properly dispensing sanitizer. On 1/24/24 at 1602 hours, a follow-up observation of the dish machine and concurrent interview was conducted with the CDM. The CDM was observed running the dish machine twice, and the water temperature was still at 100 degrees F during the wash cycle. On 1/25/24 at 1050 hours, a follow-up observation of the dish machine and concurrent interview was conducted Dietary Aide 1. Dietary Aide 1 stated the dish machine was checked by an outside repair vendor and they had to replace some of the parts of the dish machine. On 1/25/24 at 1115 hours, an interview was conducted with the Plant Operations Director. The Plant Operations Director stated he was informed of the outside repair vendor checking the dish machine, to which he showed the invoice from the outside repair vendor. Review of the invoice for the dish machine dated 1/25/24, showed, booster heater not reaching temperature. Unable to get booster heater to reach temperature due to bad heating elements. 2. On 1/24/24 at 0832 hours, an inspection of the main kitchen and concurrent interview was conducted with the Culinary Director. The sink in the main kitchen was observed continuously leaking from the faucet. The Culinary Director verified the findings. On 1/24/24 at 1350 hours, an interview was conducted with the Plant Operations Director. When the Plant Operations Director was informed of the leaking sink in the main kitchen, the Plant Operations Director called the Maintenance Assistant to inform him of the leaking sink in the main kitchen. The Maintenance Assistant stated he already checked and fixed the sink in the main kitchen. A follow-up inspection of the main kitchen and concurrent interview was conducted with the Plant Operations Director and Maintenance Assistant. The sink in the main kitchen was still observed leaking from the faucet lever. The Plant Operations Director and Maintenance Assistant verified the findings. 3. On 1/23/24 at 0834 hours, an inspection of the refrigerator used for the residents' food brought in by the visitors, and concurrent interview was conducted with the IP/DSD. An ice build-up and a brownish stain was observed in the freezer of the refrigerator used for residents' food brought in from the visitors. The IP/DSD verified the findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0657 (Tag F0657)

Minor procedural issue · This affected multiple residents

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Based on interview and medical record review, the facility failed to ensure the comprehensive plans of care for one of 13 final sampled residents (Resident 25) were revised to reflect the residents' current care needs and interventions. * The facility failed to revise the comprehensive plan of care for Resident 25's diagnosis of dementia (a memory impairment and disruption of thought process that impacts a person's ability to perform daily activities). This posed the risk of not providing the resident with individualized and person-centered care. Findings: Medical record review for Resident 25 was initiated on 1/24/24. Resident 25 was admitted tot the facility on 12/28/23, with a diagnosis of dementia. Review of Resident 25's History and Physical examination dated 12/29/23, showed Resident 25 was admitted to the facility for dementia and had no capacity to understand and make decisions. Review of Resident 25's Order Summary Report dated 1/24/24, showed a physician's order dated 12/28/23, to administer donepezil Hcl (medication used to treat dementia) 5 mg one tablet by mouth at bedtime for dementia. Review of Resident 25's plan of care showed a care plan problem dated 12/28/23, to address Resident 25's cognitive function and thought process. However, the interventions did not show specific interventions including non-pharmacological approaches to support the resident and lessen their distress and the use of the medication for dementia. On 1/25/24 at 1036 hours, an interview and concurrent medical record review for Resident 25 was conducted with RN 1. RN 1 verified Resident 25 had a diagnosis of dementia and on the medication. RN 1 was asked about Resident 25's plan of care for the diagnosis of dementia, RN 1 verified there was a plan of care for dementia and the interventions did not include the non-pharmacological approaches to lessen the resident distress and pharmacological interventions used for dementia. On 1/25/24 at 1613 hours, an interview and concurrent medical record review for Resident 25 was conducted with the DON. The DON was informed and verified 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 dispose and store trash in a sanitary manner. * The facility's two of four trash dumpsters' lids were not fully closed. One dumpster lid was fully open and another dumpster was observed overflowing with garbage, which prevented the dumpster lid to be fully closed. This failure had the potential to harbor pests. Findings: According to the US Food Code 2022 5-501.113, Covering Receptacles, showed receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids. 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 and free of surrounding litter. On 1/24/24 at 1348 hours, an observation of trash disposal and concurrent interview with the Plant Operations Director. The lids of the two of four dumpsters were observed opened. One dumpster lid was fully open and another dumpster was observed overflowing with garbage, which prevented the dumpster lid to be fully closed. The Plant Operations Director verified the findings.

Jan 2023 11 deficiencies

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

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 the notice of bed hold policy to the resident or responsible party upon transfer to the acute care facility for one of three closed sampled residents (Resident 20). This failure had the potential for Resident 20 or the responsible party to not know their rights to return to the facility. Findings: Review of the facility's P&P titled Admit/Transfer/Discharge Bed Hold dated 11/14/22, showed all residents/representatives are provided written information regarding the facility bed hold policy, which addresses holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents are provided written information about these polices at least twice: - well in advance of any transfer (e.g. in the admission packet); and - at the time of transfer (or, if the transfer was an emergency, within 24 hours) Medical record review for Resident 20 was initiated on 1/13/23. Resident 20 was admitted to the facility on [DATE], and transferred to the acute care facility on 11/21/22. Review of Resident 20's physician's order dated 11/22/22, showed an order may transfer to the acute care facility for further evaluation and treatment. Review of the Notice of Transfer or Discharge form dated 11/21/22, showed Resident 20 was to be transferred to the acute care facility. Further review of the form failed to show any notice of the bed hold per policy. On 1/13/23 at 1101 hours, an interview and concurrent record review was conducted with the SSD. The SSD verified Resident 20 was transferred to an acute care facility on 11/21/22. The SSD was asked to show documentation Resident 20 or the responsible party was notified in writing of the bed hold policy at the time of the transfer to the acute care facility. The SSD was unable to show such documentation.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the physician's order for a pommel (a device to support seating and assist with proper posture) cushion when up in wheelchair was followed for one of nine final sampled residents (Resident 3). This failure had the potential for not providing the appropriate care to the resident. Findings: Medical record review for Resident 3 was initiated on 1/10/23. Resident 3 was admitted to the facility on [DATE]. Review of the Order Summary Report dated 11/4/22, showed an order to have a pommel cushion for Resident 3 when up in the wheelchair due to leaning forward. Review of Resident 3's medical record titled Generations Care Conference - V3 dated 11/4/22, showed Resident 3's physician's order list was reviewed and discussed with a new order for pommel cushion in wheelchair. On 1/13/23 at 1040 hours, an observation was conducted with Resident 3. Resident 3 observed in bed and the resident's wheelchair was inside the bathroom with a cushion on the seat of the wheelchair. On 1/13/23 at 1120 hours, an interview was conducted with CNA 1. CNA 1 stated Resident 3 was sitting on a regular cushion, not a pommel cushion. On 1/13/23 at 1136 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 3 had a pommel cushion when she was in her wheelchair due to leaning over. On 1/13/23 at 1150 hours, a concurrent observation and follow-up interview was conducted with LVN 3. When asked if Resident 3 had a pommel cushion, LVN 3 was observed asking the Treatment Nurse. The Treatment Nurse stated it looked like a pommel cushion. LVN 3 verified and acknowledged the above findings and further stated Resident 3 should have a pommel cushion because of the physician's order. On 1/13/23 at 1239 hours, an interview was conducted with the DON. The DON acknowledged the above findings and further stated the physician's orders should be followed. On 1/13/23 at 1408 hours, a follow-up interview was conducted with the Treatment Nurse. The Treatment Nurse verified 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** 3. Review of the facility's P&P titled CPAP Administration dated 4/12/21, showed each day when the resident is removed from the machine, the reservoir should be emptied and left to air dry. Once weekly, the reservoir should be washed with warm soapy water and rinsed well, then left to air dry. Weekly cleaning should be documented in the resident record. Medical record review for Resident 273 was initiated on 1/10/23. Resident 273 was admitted to the facility on [DATE]. Review of the Order Audit Report dated 1/18/23, showed a physician's order dated 12/31/22, for CPAP at bedtime, remove when awake at bedtime and remove per schedule. Review of the H&P examination dated 12/31/22, showed Resident 273 had a diagnosis of OSA (obstructive sleep apnea-intermittent airflow blockage during sleep). The H&P examination also showed Resident 273 had the capacity to understand and make medical decisions. Review of Resident 273's Treatment Administration Record from 1/1-1/31/23, failed to show documentation the CPAP was being cleaned as per the facility's P&P. On 1/10/23 at 1137 hours, an observation and concurrent interview was conducted with LVN 1. A CPAP machine was observed at Resident 273's bedside. When asked about the facility's process in cleaning the CPAP machine, LVN 1 stated the CPAP machine was being cleaned daily using warm water then air dry. LVN 1 also stated the nurses routinely cleaned the machine when they documented in the Treatment Administration Record for applying and removing the CPAP from Resident 273. On 1/11/23 at 1034 hours, an interview was conducted with the IP. The IP was asked about the risk factors to a resident when using an unclean or dirty CPAP machine. The IP stated there was a risk for developing infection. When asked how the staff verified the CPAP machine was cleaned, the IP stated the LVNs routinely cleaned the CPAP machine every day, before and after the resident's use. When asked to show documentation of the LVNs cleaning Resident 273's CPAP machine, the IP stated they did not do any documentation for cleaning of the CPAP machine. On 1/11/23 at 1100 hours, an interview was conducted with Resident 273. When asked if the staff were cleaning her CPAP machine before and after use, Resident 273 stated no. 2. Review of the facility's P&P titled Administering Medications through a Small Volume (Handheld) Nebulizer (a small machine that turns liquid medicine into mist) revised date October 2010 showed it is the facility's policy to safely and aseptically administer aerosolized particle of medication into the resident's airway. Further review of the facility's P&P, under Steps in the Procedure section, number 29, showed to store the equipment in a plastic bag with the resident's name and the date. Review of Resident 426's medical record was initiated on 1/10/23. Resident 426 was admitted to the facility on [DATE]. Review of Resident 426's Order Summary Report showed an order dated 1/9/23, to administer ipratropium-Albuterol solution (medications used to treat and prevent symptoms of wheezing (to breathe with difficulty and with a whistling sound) 0.5-2.5(3) mg/3 ml one unit inhale orally every six hours for wheezing for five days around the clock. Review of Resident 426's MAR dated January 2023 showed to administer ipratropium-Albuterol solution 0.5-2.5(3) mg/3 ml one unit inhale orally every six hours for wheezing for five days around the clock. Further review of Resident 426's medical record showed the nebulizer treatment was administered on 1/10/23 at 0600 hours. On 1/10/23 at 1105 hours, during the initial tour of the facility, a nebulizer machine was observed on top of Resident 426's bedside table. Resident 426's nebulizer tubing was observed inside the plastic bag and was unlabeled (no name and not dated). On 1/10/23 at 1117 hours, an observation and concurrent interview and medical record review was conducted with LVN 2. When asked if Resident 426 was on the nebulizer treatment, LVN 2 stated she would like to check Resident 426's medical record. LVN 2 checked Resident 426's physician's orders and stated Resident 426 had an order for the nebulizer treatment and was last received the treatment on 1/10/23 at 0600 hours. LVN 2 acknowledged the nebulizer tubing was unlabeled. LVN 2 further stated it should be labeled for infection control reasons. LVN 2 was observed discarding the nebulizer tubing and plastic bag in the trash can. On 1/13/23 at 1239 hours, an interview was conducted with the DON. The DON acknowledged the above findings and further stated it should be labeled and dated for infection control reasons. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care and services for three of nine final sampled residents (Residents 14, 273, and 426). * The facility failed to follow and clarify the order for oxygen administration for Resident 14. The physician's order showed to administer oxygen at two lpm via nasal cannula; however, the order did not indicate whether the oxygen should be continuous or as needed. This failure put the resident at risk of not having their care needs met. * The facility failed to ensure Resident 426's nebulizer tubing was labeled as per the facility's P&P. This had the potential for increased risks of infection. * The facility failed to ensure Resident 273's CPAP machine was cleaned and the cleaning was documented in the resident's record as per the facility's P&P. This failure placed the resident at risk for infection. Findings: 1. Review of the facility's P&P titled Equipment-Oxygen Administration dated 1/1/21, showed to verify there is a physician's order for this procedure and review the physician's orders or facility protocol for oxygen administration. On 1/10/23 at 1038 hours, Resident 14 was observed in bed with an oxygen concentrator at the bedside; however, the oxygen was not being administered to the resident. Resident 14 stated she sometimes used oxygen. On 1/11/23 at 1245 hours, Resident 14 was again observed in bed with an oxygen concentrator at the bedside, but the oxygen was not being administered to the resident. Medical record review for Resident 14 was initiated on 1/10/23. Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's Order Summary Report showed an order dated 10/13/22, to administer oxygen at two lpm via nasal cannula. Review of Resident 14's Weights and Vitals Summary showed Resident 14 was administered oxygen via nasal cannula on multiple occasions since 10/13/22, but was on room air at times. For example: Resident 14 was administered oxygen via nasal cannula on the following dates and times: - On 10/15/22 at 1039 hours, - On 10/16/22 at 1710 hours, - On 10/17/22 at 1723 hours, - On 10/18/22 at 1852 hours, - On 11/5/22 at 1611 hours, - On 11/30/22 at 1930 hours, - On 12/21/22 at 1907 hours, and - On 1/2/23 at 1304 hours. Resident 14 was noted to be on room air on the following dates and times: - On 10/20/22 at 2315 hours, - On 11/4/22 at 2344 hours, - On 12/2/22 at 1226 hours, and - On 1/9/23 at 1617 hours. On 1/11/23 at 1427 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked about Resident 14's use of oxygen. LVN 1 stated Resident 14 sometimes received oxygen via nasal cannula. LVN 1 reviewed Resident 14's physician's orders and verified there was an order for oxygen at two lpm. LVN 1 stated she should clarify the order to say continuous or as needed, as it was not specific.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**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 pain management included non-pharmacological interventions for one of nine final sampled residents (Resident 14). The facility failed to provide non-pharmacological interventions prior to administration of the narcotic pain medication (a prescription medication/controlled substance which relieves pain). This failure had the potential for Resident 14 to receive unnecessary pain medication. Findings: Medical record review for Resident 14 was initiated on 1/12/23. Resident 14 was admitted to the facility on [DATE]. Review of the facility's P&P titled Pain Assessment and Management revised 3/2020 showed non-pharmacological interventions may be appropriate alone or in conjunction with medications. Review of the Order Summary Report dated 1/12/23, showed a physician's order dated 10/13/22, for non-pharmacological pain interventions as needed. The document showed the Intervention Codes as follows: 1=Redirect; 2=1:1; 3=See nurses notes; 4=iPad to Go; 5=Relaxation Techniques; 6=Food/Fluids; 7=Music; 8=Change position; 9=Adjust room temperature; 10=Backrub/Massage; 11=Pet Therapy; 12=Minimize noise and light; 13=Other; and 14=Other. Review of the Order Summary Report dated 1/12/23, showed the following physician's orders dated: - 10/13/22, to administer Butalbital-ASA-Caffeine Capsule 50-325-40 mg one capsule by mouth every 4 hours as needed for headaches/migraine; - 10/13/22, to administer Gabapentin Capsule 300 mg two capsules by mouth three times/day for nerve pain; - 11/3/22, to apply Dicolfenac Sodium Gel 1% to the back topically three times/day for pain management, apply 2GM=2.25 inches; - 10/21/22, to administer Oxycodone HCL ER 12 hour Abuse Deterrent 20 mg one tablet by mouth every 12 hours for lumbar pain; and - 1/9/23, to administer Oxycodone HCL tablet 10 mg one tablet by mouth every 6 hours as needed for back and/or sacral pain. Review of Resident 14's MAR from October 2022 through January 2023, showed Resident 14 received Oxycodone HCL PRN on the following dates: - 10/14, 10/17, 10/18, 10/19, 10/20, and 10/21/22. - from 11/1 -11/19, 11/21-11/27, 11/29 and 11/30/22. - from 12/8-12/19, 12/21-12/27, 12/29 and 12/30/22. - 1/1 -1/8/23 However, further review of the MAR failed to show documentation of non-pharmacological pain interventions attempted as ordered. On 1/12/23 at 1147 hours, an interview was conducted with LVN 2. When asked if the non-pharmacological interventions were offered or attempted to Resident 14 for pain management prior to the administration of the pain medication, LVN 2 stated they did, such as repositioning; however, Resident 14 asked for her pain medication right away. When asked to show documentation of the non-pharmacological interventions offered or provided to Resident 14, LVN 2 stated she would consult with the DON. On 1/1/2/23 at 1150 hours, an interview was conducted with the DON. When asked to show the documentation for non-pharmacological interventions, the DON verified in the PCC MAR, the dates when the PRN pain medication were administered to Resident 14, the non-pharmacological interventions sections were blank and the staff did not document their attempts of providing non-pharmacological interventions prior to administering the PRN pain medication. On 1/12/23 at 1318 hours, an interview was conducted with Resident 14. Resident 14 was asked if she was offered non-pharmacological pain relief, such as massages. Resident 14 stated nothing was offered to her.

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** 3. Medical record review for Resident 472 was initiated on 01/10/23. Resident 472 was admitted to the facility on [DATE], with the diagnosis of anemia. Review of Resident 472's Order Summary Report for the month of January showed Resident 472 was ordered Enoxaparin injections (a blood thinner medication) daily. The medication order showed, ppx (abbreviation for prophylaxis) and did not show any further indication for use. Review of Resident 472's MAR for the month of January showed Resident 472 received Enoxaparin every day since admission on [DATE]. On 01/13/23 at 1218 hours, an interview and concurrent medical record review was conducted with LVN 3 who stated she had given Resident 472 Enoxaparin injections. When asked what the indication for use was, LVN 3 stated she did not know why Enoxaparin was ordered and further explained during medical record review that the physician's order did not list the indication for use. LVN 3 stated the physician order should show the prophylaxis reason. On 01/13/23 at 1303 hours, an interview was conducted with the DON who stated an indication for use of the medication was the most important part of the medication order. When asked if prophylaxis alone would suffice as an indication, she stated no and explained that a medication order should show what the prophylaxis was for. On 01/13/23 at 1400 hours, an interview was conducted with Consultant Pharmacist 1. When asked what the minimum components of medication order were, the Consultant Pharmacist stated the medication orders should include the indication for use. On 01/13/23 at 1500 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 follow the physician's orders and obtain an indication for the use of medication for one of nine final sampled residents (Resident 472), and failed to monitor for the medication side effects for one of five unnecessary medication sampled residents (Resident 274). * LVN 2 placed a pain medication patch on Resident 472's lower back instead of anterior ribs as per the physician's orders. This failure put Resident 472 at risk for adverse effects. * Resident 274 was administered Eliquis (an anticoagulant medication used to treat or prevent blood clots) without any monitoring in place for adverse effects such as bleeding and bruising. This failure put Resident 274 at risk for dangerous side effects to go unnoticed. * Resident 472 was given Enoxaparin injections (a blood thinner medication) without an indication for use listed on the medication order. This failure had the potential to cause Resident 472 harm from unnecessary use of a blood thinner. Findings: Review of the facility's P&P titled Administering Medications revised date 4/19 showed the medications are administered in accordance with the prescriber's orders. 1. Medical record review for Resident 472 was initiated on 1/11/23. Resident 472 was admitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 1/9/23, for lidocaine patch 5% (a medication used to treat pain) one patch intradermally (within the skin) one time a day, apply to anterior (situated before or toward the front) ribs for 12 hours, on at 0900 hours and off at 2100 hours and remove per schedule. On 01/11/23 at 0905 hours, a medication administration observation was conducted with LVN 2. LVN 2 prepared the medications to administer to Resident 472 including a lidocaine 5% patch. LVN 2 explained to Resident 472 that she would apply the lidocaine patch. Resident 472 told LVN 2 to place the patch on her lower back. LVN 2 applied the lidocaine patch to Resident 472's lower back, just above the gluteal (buttocks) fold. On 01/11/23 at 1425 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 was asked about the placement of Resident 472's lidocaine patch. LVN 2 stated she applied the patch to the lower back because Resident 472 requested her to do so, but stated she should have clarified the physician's order. On 1/13/23 at 1419 hours, an interview was conducted with the DON. The DON was asked about the process when a resident requested for a patch to be placed somewhere other than what was in the physician's order. The DON stated the licensed staff should follow the physician's order and clarify any orders with the physician before changing the site of administration. 2. According to Lexicomp (an online medication database), under Nursing Physical Assessment/Monitoring for Eliquis, the following should be done: - Check ordered labs and report any abnormalities. Monitor for signs and symptoms of bleeding (bruising or bleeding that is not normal, changes in menstrual periods like lots of bleeding, spotting, or bleeding between cycles, nosebleeds that won't stop, bowel movements that are red or black like tar, throwing up blood or liquid that looks like coffee grounds). - Educate patients on bleeding precautions including avoiding invasive procedures, activities that could cause injuries, and how to handle bleeding emergencies. - Educate patients that grapefruit juice may increase the effects of the medication. Instruct patients not to discontinue medication prematurely. Advise patients to tell all doctors and dentists about use of an anticoagulant. Medical record review for Resident 274 was initiated on 1/13/23. Resident 274 was admitted to the facility on [DATE]. Review of Resident 274's Order Summary Report showed an order dated 1/6/23, to administer Eliquis 2.5 mg one tablet twice per day as a blood thinner, deep vein thrombosis preventing knee replacement. Review of Resident 274's medical record failed to show any monitoring for side effects such as excess bleeding or bruising. On 1/13/23 at 1052 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 was asked if there were any special considerations when a resident received an anticoagulant. LVN 1 stated the residents on anticoagulants should be monitored for bleeding. LVN 1 was asked to review Resident 274's medical record. LVN 1 verified Resident 274 received Eliquis 2.5 mg twice daily. When asked to show documentation of monitoring was in place, LVN 1 was unable to show. On 1/13/23 at 1209 hours, an interview was conducted with the DON. The DON was asked for the process when a resident was on an anticoagulant. The DON stated the residents on anticoagulants should be monitored for side effects such as bleeding and it would be documented on the MAR. Cross reference: F756

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 472 was initiated on 01/10/23. Resident 472 was admitted to the facility on [DATE], with the diagnosis of anemia. Review of Resident 472's Order Summary Report for the month of January 2023 showed Resident 472 was ordered Enoxaparin injections (a blood thinner medication) daily. The medication order showed, ppx (abbreviation for prophylaxis) and did not show further indication for use. Review of Resident 472's MAR for the month of January 2023 showed Resident 472 received Enoxaparin every day since admission on [DATE]. Review of Resident 472's pharmacy consultation report dated 01/11/23, showed the pharmacist reviewed Resident 472's medication regimen with no recommendations for change. On 01/13/23 at 1303 hours, an interview was conducted with the DON who stated an indication for the use of the medication was the most important part of the medication order. When asked if prophylaxis alone would suffice as an indication, she stated no and explained a medication order should include what the prophylaxis was for. On 01/13/23 at 1400 hours, an interview was conducted with Consultant Pharmacist 1 who stated the pharmacists reviewed the resident's medication orders monthly and upon admission. Consultant Pharmacist 1 further stated during the medication reviews, the pharmacists checked if the medication orders were complete. Consultant Pharmacist 1 stated they had to ensure the medications with an appropriate diagnosis. When asked what the minimum components of a medication order were, Consultant Pharmacist 1 stated the medication orders should list the indication for use. Consultant Pharmacist 1 stated if the indication was missing from an order, the facility would be notified through the pharmacy consultation report. On 01/13/23 at 1500 hours, the DON and Administrator were informed and acknowledged the above findings. Based on interview and medical record review, the facility failed to ensure the pharmacist reported irregularities in the medical record to the attending physician, medical director, and DON for two of five unnecessary medication sampled residents (Residents 274 and 472). * Resident 274 received an anticoagulant medication without any order for side effects monitoring. The pharmacist failed to notice and provide a recommendation to the facility. This failure had the potential for Resident 274's side effects to go unnoticed. * Resident 472 was given Enoxaparin injections (a blood thinner medication) without an indication for use listed on the medication order. The pharmacist failed to flag and provide recommendations for this medication. This failure had the potential to cause Resident 472 harm from unnecessary use of a blood thinner. Findings: 1. According to Lexicomp (an online medication database), under Nursing Physical Assessment/Monitoring for Eliquis, the following should be done: - Check ordered labs and report any abnormalities. Monitor for signs and symptoms of bleeding (bruising or bleeding that is not normal, changes in menstrual periods like lots of bleeding, spotting, or bleeding between cycles, nosebleeds that won't stop, bowel movements that are red or black like tar, throwing up blood or liquid that looks like coffee grounds). - Educate the patients on bleeding precautions including avoiding invasive procedures, activities that could cause injuries, and how to handle bleeding emergencies. - Educate the patients that grapefruit juice may increase the effects of the medication. - Instruct the patients not to discontinue medication prematurely. - Advise the patients to tell all doctors and dentists about use of an anticoagulant. Medical record review for Resident 274 was initiated on 1/13/23. Resident 274 was admitted to the facility on [DATE]. Review of Resident 274's Order Summary Report showed an order dated 1/6/23, to administer Eliquis 2.5 mg one tablet twice per day as a blood thinner, deep vein thrombosis preventing knee replacement. Review of Resident 274's medical record failed to show any monitoring for the side effects such as excess bleeding or bruising. Review of the Pharmacist's Consultation Report dated 1/9/23, showed Resident 274's medication regimen review with no new irregularities, and there were no recommendations. On 1/13/23 at 1209 hours, an interview was conducted with the DON. The DON was asked the process for medication regimen review. The DON stated the Consultant Pharmacist would review all resident's medication orders on a monthly basis. The pharmacist then would shares the recommendations with the facility. The DON verified Resident 274 had an order for Eliquis in place since 1/6/23. On 1/13/23 at 1217 hours, a telephone interview and concurrent medical record review was conducted with Consultant Pharmacist 1. Consultant Pharmacist 1 was asked her process when she did the medication regiment review, specifically for Eliquis. Consultant Pharmacist 1 stated she would look for interactions. Consultant Pharmacist 1 stated when a resident on an anticoagulant, they should be monitored for signs and symptoms of bleeding and bruising. Consultant Pharmacist 1 verified Resident 274's medical record was reviewed on 1/9/23, but no recommendations were given. Consultant Pharmacist 1 stated the side effect monitoring was normally and should be included in the reviews. Cross reference to F755, example #2.

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 expired medications in the Medication Room were disposed. This failure had the potential for the expired medications to be administered to the residents. Findings: Review of the facility's P&P titled Storage of Medication revised date 11/20 showed discontinued, outdated, or deteriorated drugs or biological's are returned to the dispensing pharmacy or destroyed. On 1/11/23 at 0941 hours, an observation and concurrent interview was conducted with RN 1 in the Medication Room. Various over the counter medications were observed stored in the cupboards. One bottle of Co Q-10 (a supplement used for heart health) was observed in the cupboard with an expiration date of 9/22. When asked how the medications were stored, RN 1 stated they used a first in first out system, so the medications with soonest expiration date were placed to the front. RN 1 stated all licensed staff were responsible to rotate the medications and dispose of the expired medications, and the expired medication should not have been there.

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 473 was initiated on 01/10/23. Resident 473 was admitted to the facility on [DATE], with the diagnosis of iron deficiency anemia, vitamin B12 deficiency anemia, and severe protein calorie malnutrition. On 01/10/23 at 1220 hours, during concurrent meal observation and interview in the dining room, CNA 2 brought Resident 473 his meal tray. Resident 473's meal ticket had soft and bite sized vegetables marked off. However, upon observation of Resident 473's meal tray, no vegetables were served. When asked if Resident 473 had received all the food ordered, CNA 2 stated Resident 473 did not receive vegetables as marked on the meal ticket. On 01/13/23 at 1040 hours, an interview was conducted with the Culinary Director who oversaw the resident menu and meals. When asked to explain the purpose of meal tickets, the Culinary Director stated the meal tickets were based off the menu she created for the month. She stated the CNAs met with residents daily to obtain their meal preferences and check off the food items on the meal ticket for meals on the following day. The meal ticket was based on what the resident said they wanted for their meal. The Culinary Director further stated all the food or food substitutions listed on a resident's meal ticket should be served to ensure the resident received their necessary caloric intake. On 01/13/23 at 1500 hours, the DON and Administrator were informed and acknowledged the above findings. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed and residents' nutritional needs were met when: * Puree recipes were not followed. * Correct portion size was not followed. * Resident 473 was not provided food as listed on his meal ticket. This failure had the potential to cause physical and psychosocial harm to Resident 473. These failures had the potential for the residents receiving food prepared in the kitchen to not meet their nutritional needs which may lead to nutritional related health complications. Findings: 1. Review of the facility's P&P tilted Standard Portions revised 9/1/18, showed to provide proper equipment for portioning out the correct quantity of food for the residents; the recipes and menus should have the appropriate portions noted; and the portion sizes must be accurate on each diet. On 1/11/23 at 1120 hours, an observation of the puree preparation for the lunch meal was conducted with [NAME] 1. [NAME] 1 stated he was pureeing food for two servings. [NAME] 1 was observed placing five pieces of cooked meat, unmeasured, added two four ounces of applesauce and two tablespoon of meat broth, then blended the mixture. The blended mixture of meat and applesauce was put in a steamtable pan, covered, and placed inside the hotbox (a storage and transport of cooked meals). The Culinary Director stated the residents only wanted the meat and veggies. Review of the facility's document titled Recipe undated, showed Applesauce Pork Chops, five servings of four ounces cooked meat portions. However, during the observation of puree preparation, [NAME] 1 was not observed measuring the pork chops. In addition, no measurement of applesauce was stated in the recipe used. On 1/12/23 at 0940 hours, an interview was conducted with the Culinary Director. The Culinary Director stated [NAME] 1 weighed the meat prior to puree preparation. In addition, the Culinary Director stated apple sauce was added to the meat instead of the liquid that was stated in the recipe. The Culinary Director acknowledged the findings and further stated the recipe should be followed. 2. Review of the facility's P&P tilted Standard Portions revised 9/1/18, showed to provide proper equipment for portioning out the correct quantity of food for the residents; the recipes and menus should have the appropriate portions noted; and the portion sizes must be accurate on each diet. Review of the facility's document titled Week at a Glance a weekly menu dated 1/8/23 to 2/11/23, showed for the lunch meal on 1/11/23, Pork Chop with Apples, Red Bliss Potatoes, Brussels Sprouts with cranberries, and Bread or Roll and Butter or Margarine were to be served. On 1/11/23 at 1114 hours, an observation of the lunch meal service was conducted with Dietary Aide 1. Dietary Aide 1 was observed serving the pureed meat with applesauce mixture using number 10 scoop (three ounces). Review of the facility's document titled Daily Spreadsheet (a document which referenced portion sizes and therapeutic diet extensions) dated 1/8/23 to 2/11/23, showed for puree diets on 1/11/23, # eight scoop (four ounces) of puree meat and #16 scoop (two ounces) of puree apples. On 1/12/23 at 0940 hours, an interview was conducted with the Culinary Director. When asked how to have the correct portions, the Culinary Director stated to round up the mixture and divided by two, which made two of the #12 scoop (2.6 ounces). The Culinary Director further stated [NAME] 1 should have told Dietary Aide 1 on what scoop number to use when serving the puree meat mixture, and Dietary Aide 1 should have followed the spreadsheet for nutritional value purposes. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian was informed of the findings and stated the spreadsheet should be followed.

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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Based on observation, interview, and facility P&P review, the facility failed to ensure proper infection control practices during the medication administration observation. LVN 2 missed multiple opportunities for hand hygiene when preparing and administering Resident 426's medications. This failure put the residents at risk for infection. Findings: Review of the facility's P&P titled Handwashing/Hand Hygiene revised date 8/19 showed the facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively soap and water for the following situations: - before and after direct contact with residents - before preparing or handling medications - after removing gloves On 1/11/23 at 0839 hours, a medication administration observation and concurrent interview was conducted with LVN 2. LVN 2 prepared the medications to administer to Resident 426. LVN 2 put each medication into a medicine cup. LVN 2 then donned gloves without performing hand hygiene and administered the medications to Resident 426. LVN 2 then prepared medications to administer to Resident 472, including a patch and breathing treatment. LVN 2 put the medications into a medicine cup, and then donned gloves without performing hand hygiene. LVN 2 then administered the medications to Resident 472. First, LVN 2 assisted Resident 472 with the oral (by mouth) medications, then administered the breathing treatment. After administering the breathing treatment, LVN 2 removed her gloves and donned a new pair gloves without performing hand hygiene. LVN 2 then assisted Resident 472 by picking up a used tissue from the floor and placing it in the trash receptacle. LVN 2 then removed her gloves and donned a new pair without performing hand hygiene. LVN 2 was asked when hand hygiene should be performed. LVN 2 stated hand hygiene should be performed between glove changes.

CONCERN (E)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected multiple residents

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Based on interview and facility document review, the facility failed to have a full-time qualified individual employed to oversee the day-to-day food service operations in the SNF. This failure posed a risk of lack of adequate supervision of the daily kitchen functions which could lead to food borne illness for the 16 residents who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/10/23, showed 16 of 18 residents received food prepared in the kitchen. According to the California Code, Health, and Safety Code - HSC § 1265.4: A licensed health facility, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a qualified full-time dietetic services supervisor to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. Review of the facility's general job summary titled Culinary Director dated 6/12/20, showed the Culinary Director is responsible for organizing, developing, and directing the overall operation of the culinary department to ensure that quality nutritional services are provided on a daily basis and the culinary services are maintained in a clean, safe, and sanitary manner, as well as other job duties. Further review of the facility's document showed the Culinary Director's signature dated 9/1/20. On 1/10/23 at 0915 hours, an interview was conducted with the Culinary Director. The Culinary Director stated she was working fulltime for both ALF and SNF. The Culinary Director further stated all food were prepared in the main kitchen and the Registered Dietitian was employed part-time. On 1/11/23 at 1450 hours, an interview was conducted with the Administrator. The Administrator stated the Culinary Director oversaw the whole building, both ALF and SNF. The Administrator further stated the Registered Dietitian visited once a week. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated she was a consultant for the facility. The Registered Dietician further stated the Culinary Director oversaw both ALF and SNF.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and facility P&P review, the facility failed to ensure the food safety and sanitary requirements were met in the dietary department as evidenced by the following: * The facility failed to ensure the thawing of frozen food in the walk-in refrigerator of the main kitchen was labeled and dated. * The facility failed to ensure the plumbing for the ice machine in the main kitchen had an air gap. * The facility failed to ensure the opened food item in the walk-in refrigerator of the main kitchen was dated. * The facility failed to ensure the proper sanitary condition of kitchen equipment. * The facility failed to ensure the kitchen equipment in the main kitchen was in sanitary condition and with a cleanable surface. * The failed to ensure the safe storage of food items in the reach-in the refrigerator of the SNF satellite kitchen . * The facility failed to ensure the kitchen staff personal belongings were stored away from the kitchen preparation area. These failures had the potential to cause foodborne 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 Health Information Specialist dated 1/10/23, showed 16 of 18 residents residing in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised date 3/9/20, under the Frozen Meat/Poultry and Foods section - thawing, showed to date meat when taken out of the freezer. During the initial tour of the main kitchen with the Culinary Director on 1/10/23 at 0923 hours, an observation in the main kitchen walk-in refrigerator showed two bags of chicken unlabeled and undated on the bottom rack. The Culinary Director verified the findings and further stated it should have been labeled and dated when it was taken out of the box. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated it should be labeled and dated. 2. According to the USDA Food Code 2017 under section 5-202.13 titled Backflow Prevention, Air Gap, showed an air gap between the water supply inlet (pipe inlet) and the flood level rim of the plumbing fixture or equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. The food code showed if a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the whole system. During the initial tour of the main kitchen with the Culinary Director on 1/10/23 at 0923 hours, two pipes draining water from the ice machine were observed below the flood level of the floor drain. On 1/11/23 at 1039 hours, a concurrent observation and interview was conducted with the Maintenance Assistant. The Maintenance Assistant acknowledged the above findings and further stated he would raise up the drain pipes. 3. Review of the facility's P&P titled Refrigerated Storage Chart revised date 12/28/20, under the dairy products section showed the whipping cream when opened can be stored for one week. During the initial tour of the main kitchen walk-in refrigerator with the Culinary Director on 1/10/23 at 0923 hours, one Richs on Top whipped topping, was observed opened and undated. The Culinary Director verified findings and further stated it should be dated when opened. The Culinary Director was observed discarding the whipped cream in the trash can. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated it should be labeled and dated. 4. According to the FDA Food Code 2017, Section 4-601.11 Equipment, Food-Contact Surfaces, Non-Food Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. (B) the Food-Contact Surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulation. (C) Nonfood Contact Surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. a. During the initial tour of the main kitchen with the Culinary Director on 1/10/23 at 0923 hours, a food slicer was observed to have black and brown unknown dry debris on the back of the blade and other components. The Culinary Director verified and acknowledged findings. The Culinary Director further stated all parts of the food slicer should be cleaned after each use and should be covered. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated it should be clean. b. During the initial tour of the main kitchen with the Culinary Director on 1/10/23 at 0923 hours, two large frying pans with black discoloration and scratches inside of the pan, one small frying pan with black discoloration inside of the pan, and one small nonstick frying pan with scratches inside of the pan were observed. The Culinary Director verified the findings and further stated the two large and one small frying pans were stainless steel pans. The Culinary Director was observed discarding all four frying pans in the trash can. c. During the initial tour of the satellite kitchen in the SNF with the Culinary Director on 1/10/23 at 0923 hours, a food blender machine was observed on top of the shelf with wet yellow debris on the cap. The Culinary Director verified findings and further stated it could cause cross contamination. 5. During the initial tour of the satellite kitchen in the SNF with the Culinary Director on 1/10/23 at 0923 hours, one red spatula was observed with melted edges. The Culinary Director verified the findings and further stated it could cause a contamination to the food. 6. Review of the facility's P&P titled Refrigerated Storage Chart revised 12/28/20, under the dairy products section showed shakes or supplements should be stored per manufacturers guidelines. On 1/11/23 at 0908 hours, a concurrent observation and interview was conducted with Dietary Aide 1. Multiple boxes of health shakes in the reach-in refrigerator of the satellite kitchen were observed undated. Dietary Aide 1 stated the health shakes was taken out of the freezer on 1/9/23. On 1/11/23 at 0919 hours, a concurrent observation and interview was conducted with the Culinary Director. When asked about how long the health shakes in the reach-in refrigerator should be stored, the Culinary Director stated it should be by the expiration date. Then the Culinary Director proceeded to read the label on the health shake box. The Culinary Director showed the health shakes box was labeled use thawed product within 14 days. The Culinary Director acknowledged the findings and further stated it should have a used by date sticker. 7. According to the USDA Food Code 2017, 6-501.110, personal belongings can contaminate, food, food equipment and food contact surfaces. Review of the facility's P&P titled Personal Hygiene - Safety - Food Handling revised dated 11/30/22, under Designated Area for Employee Personal Belongings section showed personal belongings, beverages, and/or food may be stored in the designated area. On 1/10/23 at 1015 hours, an observation of the food preparation area was conducted during the initial tour of the main kitchen with the Culinary Director. The rolled plaid clothing and white-water bottle were observed on the top shelf of the food preparation area in the three-compartment sink. The Culinary Director and Dishwasher 1 verified the findings. The Culinary Director further stated the personal belongings should be in the locker room. On 1/12/23 at 1034 hours, a telephone interview was conducted with the Registered Dietitian. The Registered Dietitian stated it should be not in the kitchen area.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• $4,368 in fines. Lower than most California facilities. Relatively clean record.
• 43% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• 56 deficiencies on record. Higher than average. Multiple issues found across inspections.

Bottom line: Mixed indicators with Trust Score of 68/100. Visit in person and ask pointed questions.

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About This Facility

What is Bayshire Yorba Linda Post-Acute's CMS Rating?

CMS assigns BAYSHIRE YORBA LINDA POST-ACUTE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Bayshire Yorba Linda Post-Acute Staffed?

CMS rates BAYSHIRE YORBA LINDA POST-ACUTE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 43%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Bayshire Yorba Linda Post-Acute?

State health inspectors documented 56 deficiencies at BAYSHIRE YORBA LINDA POST-ACUTE during 2023 to 2025. These included: 52 with potential for harm and 4 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Bayshire Yorba Linda Post-Acute?

BAYSHIRE YORBA LINDA POST-ACUTE 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 BAYSHIRE SENIOR COMMUNITIES, a chain that manages multiple nursing homes. With 45 certified beds and approximately 37 residents (about 82% occupancy), it is a smaller facility located in YORBA LINDA, California.

How Does Bayshire Yorba Linda Post-Acute Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, BAYSHIRE YORBA LINDA POST-ACUTE's overall rating (4 stars) is above the state average of 3.2, staff turnover (43%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.

What Should Families Ask When Visiting Bayshire Yorba Linda Post-Acute?

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

Is Bayshire Yorba Linda Post-Acute Safe?

Based on CMS inspection data, BAYSHIRE YORBA LINDA POST-ACUTE 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 4-star overall rating and ranks #1 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 Bayshire Yorba Linda Post-Acute Stick Around?

BAYSHIRE YORBA LINDA POST-ACUTE has a staff turnover rate of 43%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Bayshire Yorba Linda Post-Acute Ever Fined?

BAYSHIRE YORBA LINDA POST-ACUTE has been fined $4,368 across 1 penalty action. This is below the California average of $33,123. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Bayshire Yorba Linda Post-Acute on Any Federal Watch List?

BAYSHIRE YORBA LINDA POST-ACUTE 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: 45
Avg. Residents: 37
Occupancy: 83.8%
Ownership: For profit - Individual
Chain: BAYSHIRE SENIOR COMMUNITIES
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
4-Star Rating: +30
56 Deficiencies: -10
Fines ($4,368): -2
Final Score: 68/100

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 YORBA LINDA →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555768