How many inspection deficiencies does BRIDGEVIEW POST ACUTE have?

BRIDGEVIEW POST ACUTE has 73 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at BRIDGEVIEW POST ACUTE?

BRIDGEVIEW POST ACUTE has a four-star staffing rating from CMS with 0.71 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 BRIDGEVIEW POST ACUTE located?

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

How many beds does BRIDGEVIEW POST ACUTE have?

BRIDGEVIEW POST ACUTE has 130 certified beds.

Who owns BRIDGEVIEW POST ACUTE?

BRIDGEVIEW POST ACUTE is a for profit - limited liability company facility and is part of the WEST HARBOR HEALTHCARE chain.

What questions should families ask when visiting BRIDGEVIEW POST ACUTE?

Families visiting BRIDGEVIEW POST ACUTE should ask about what corrective actions were taken after fines. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does BRIDGEVIEW POST ACUTE compare to other nursing homes?

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

BRIDGEVIEW POST ACUTE

Q: What is BRIDGEVIEW POST ACUTE's CMS rating?

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

Q: Is BRIDGEVIEW POST ACUTE safe?

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

Q: Do nurses at BRIDGEVIEW POST ACUTE stick around?

BRIDGEVIEW POST ACUTE has average staff turnover at 41%, which is typical for the nursing home industry.

Q: Was BRIDGEVIEW POST ACUTE ever fined?

Yes, BRIDGEVIEW POST ACUTE has been fined $88,927 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Q: Is BRIDGEVIEW POST ACUTE on any federal watch list?

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

521 LOREL WAY, YUBA CITY, CA 95991 · (530) 674-9140

For profit - Limited Liability company 130 Beds WEST HARBOR HEALTHCARE Data: November 2025

Trust Grade

25/100

#754 of 1155 in CA

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Last Inspection: October 2024

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

Overview

Bridgeview Post Acute has received a Trust Grade of F, indicating significant concerns and a poor overall evaluation. They rank #754 out of 1155 facilities in California, placing them in the bottom half, and are the lowest-ranked among the four nursing homes in Sutter County. The facility is improving, with a decrease in issues from 23 in 2024 to just 3 in 2025. Staffing is a relative strength, earning a 4 out of 5 stars, with a turnover rate of 41%, which is about average for the state. However, the facility has incurred $88,927 in fines, which is higher than 85% of California facilities, raising concerns about compliance issues. Specific incidents of concern include a resident who developed a severe pressure ulcer due to a lack of timely assessment and treatment, and another resident who experienced significant weight loss without proper monitoring or intervention. While the facility does provide better RN coverage than 81% of state facilities, these serious deficiencies highlight the need for families to carefully consider the overall quality of care provided at Bridgeview Post Acute.

Trust Score: F
In California: #754/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 41% turnover. Near California's 48% average. Typical for the industry.
Penalties: $88,927 in fines. Lower than most California facilities. Relatively clean record.
Skilled Nurses: Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for California. RNs are trained to catch health problems early.
Violations: 73 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★★★☆

4.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 23 issues

2025: 3 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (41%)
7 points below California average of 48%

Facility shows strength in staffing levels, fire safety.

The Bad

2-Star Overall Rating

Below California average (3.1)

Below average - review inspection findings carefully

Staff Turnover: 41%

Near California avg (46%)

Typical for the industry

Federal Fines: $88,927

Well above median ($33,413)

Moderate penalties - review what triggered them

Chain: WEST HARBOR HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 73 deficiencies on record

3 actual harm

Aug 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an abuse allegation for one of five sampled residents (Resident 4) when Resident 4 informed staff that they had been slapped in the face by another resident on 6/20/25. This failure had the potential to result in psychosocial and emotional harm for Resident 4 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse.Findings:During a review of the facility's policy titled, Abuse Investigation and Reporting, revised 7/2017, indicated that:1. All reports and findings of resident abuse shall be reported to local, state and federal agencies, and thoroughly investigated by facility management.2. All alleged violations involving abuse will be reported by the facility Administrator to the state licensing/certification agency responsible for surveying/licensing the facility. During a review of Residents 4's admission record, indicated Resident 4 was admitted on [DATE] with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), high blood pressure, and muscle weakness. During a review of Resident 4's most recent Minimum Data Set (MDS - an assessment and care screening tool), dated 6/19/25, the MDS indicated that Resident 4 had a brief interview for mental status (BIMS) score of 15 out of 15, indicating her cognition was not impaired. During a review of record titled progress Notes, dated 6/22/25, indicated that staff reported an incident between Resident 4 and Resident 5 where Resident 5 ran into Resident 4 with their wheelchair and then slapped Resident 4 on the face and chest. During a concurrent interview and record review on 8/12/25 at 12:30 pm with the Administrator (ADN), the record titled, Report of Suspected Dependent Adult/Elder Abuse, dated 6/20/25, indicated, that Resident 4 had been slapped on the face and chest by Resident 5 leaving Resident 4 with discoloration and scratches on the chest. ADN confirmed that the incident had occurred but was not reported to the state licensing/certification agency. ADN stated that it was their understanding that the facility was not required to report abuse if the perpetrator had a diagnosis of dementia. During an interview on 8/12/25 at 1 pm with the Director of Nursing (DON), the DON confirmed that there had been an incident on 6/20/25, where Resident 4 had been slapped by Resident 5. The DON stated that according to an All Facilities Letter (AFL) the facility was no longer required to report abuse that involved a perpetrator with a dementia diagnosis. The DON confirmed that the abuse incident had not been reported to the state licensing/certification agency.

Jun 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 1 and Resident 2) were free from accidents and hazards when: a) post fall evaluations did not determine the reason for the falls. b) residents care plan interventions were not reevaluated for effectiveness. c) new interventions were not developed prevent further falls and injuries. d) direct care staff did not know how to identify high risk fall residents and find their fall plan of care. This resulted in multiple repeated resident falls and had the potential for all residents to be at risk for fall/injuries. Findings: A review of the facility ' s policy titled Clinical Protocol for Falls, revised March 2018, indicated under: Treatment/Management 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation (for example, if the individual continues to try to get up and walk without waiting for assistance). Monitoring and Follow-Up 2. The staff and Physician will monitor and document the individual ' s response to interventions intended to reduce falling or the consequences of falling. a. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. 4. If the individual continues to fall the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident ' s falling (instead of, or in addition to those that have already been identified) and reconsider the current interventions. 1. A review of Resident 1 ' s records indicated they were admitted to the facility on [DATE], with diagnoses which included unspecified dementia, difficulty in walking, anxiety disorder, and repeated falls. A review of a Minimum Data Set (MDS, resident assessment) dated 2/06/2025, indicated Resident 1 was cognitively intact. A review of a fall risk assessment dated [DATE], indicated Resident 1 was a high fall risk. A review of Interdisciplinary (IDT, a group of healthcare disciplines that develop plan of care) note dated, for a fall on 2/27/2025 at 12 am, Resident 1 fell outside his room in the hallway, unwitnessed with a skin tear to left elbow. New intervention was to provide one on one (1:1, direct staff observation always) for evening (PM) and night shift (NOC). A review of Resident 1 ' s Care Plan, dated 2/27/2025 interventions: Will provide 1:1 Certified Nursing Assistant (CNA) for PM and NOC shifts. A review of IDT note dated, for a fall on 3/01/2025 at 12:15 am, Resident 1 wandered into room [ROOM NUMBER] another resident ' s room to use the bathroom and was found on laying on his back on the floor near the toilet. New intervention toileting program (timed assistance for bathroom use). A review of Resident 1 ' s Care Plan, dated 3/01/2025 interventions: encourage resident to use call bell initiated 3/01/2025 (repeated intervention). Toileting program initiated 3/03/2025. A review if Resident 1 ' s IDT dated, for a fall on 3/04/2025 at approximately 3:00 am Resident 1 became agitated and wanted to get out of bed. Resident 1 was transferred into a wheelchair. Resident 1 became verbally abusive to staff at the nurse ' s station. Resident 1 kept attempting to pull himself on the rails of the hallway. Nursing staff tried to redirect Resident 1, and he became combative. Resident 1 began to roam the hallways. Nursing staff was stationed in the hallways to monitor the resident ' s whereabouts. At 4 :30 am, the Resident 1 was observed in the hallway lying supine (flat on his back, face up) on ground with Hoyer Lift (resident assistive device for transfers) on top of him. New Intervention transfer to the hospital for treatment and evaluation. Encourage ambulation with assistance. A review of Resident 1 ' s Care Plan, dated 3/04/2025 interventions: assess for injury, vital signs taken, and send resident to emergency department for evaluation and treatment. A review of Resident 1 ' s IDT note dated, for a fall on 3/06/2025 at 9:30 am, Resident 1 had and unwitnessed fall in the therapy room. Ten minutes prior to fall Resident 1 was in his room eating and activities of daily living) was being done. Resident 1 propelled himself into the hallway. Resident 1 was assessed by nurse, no injuries, vital signs within normal limits and metal status remained baseline. New intervention: Refer to Restorative Nursing Assistant (RNA, specializes in care and support for residents with mobility, strength, or functional limitations) for ambulation. No evaluation of effectiveness of 1:1 for PM and NOC shifts and no discussion of increasing supervision for day shift falls. A review of Resident 1 ' s IDT note dated, for a fall on 3/25/2025 at 6:30 pm, nursing staff witnessed Resident 1 sliding off the bed. Immediate assistance was provided, ensuring the resident safely came to rest on the landing pad adjacent to the bed. No injuries or trauma sustained. New intervention: re-implement one-to-one supervision after following acute care back on 3/4/25. No evaluation of effectiveness of previous fall interventions such as how it was determined to remove the 1:1 for Resident 1. A review of Residents 1 ' s Care Plan, dated 3/25/2025 Intervention: transferring the patient to a room near the nurse ' s station. Educating the resident about bed controls and call bell (repeated intervention). A review of Resident 1 ' s IDT note dated, for a fall on 4/12/2025 at 3:10 pm Resident 1 was seen sliding down in his wheelchair with his feet in front of him and upper body in his wheelchair. Staff intervened and tried to reposition him, but resident slid down to the floor. Prior to incident resident was last seen sitting in his wheelchair with nonskid shoes on, when resident was asked what happened resident stated, he wanted to get up and walk. Skin assessment revealed new trauma wound to right great toe. New Interventions wound nurse evaluated and treated, cushion for wheelchair. A review of Resident 1 ' s Care Plan, dated 4/12/25 interventions: Orient the resident to the environment and safety measures. Advise the resident about the location of the Educate the resident about bed controls and call bell. Keep bed position low. Place slip resistant shoes or socks with grips (all repeated prior interventions). No evaluation of effectiveness of previous fall interventions. A review of Resident 1 ' s records indicated he had eleven falls at facility since admission. Five of 11 falls occurred on day shift on 1/31/2025 at approximately 7:15 am, 3/01/2025 at approximately 12:15 pm, 3/06/2025 at approximately 9:30am, 3/25/2025 at approximately 6:30 pm, and 4/12/2025 at approximately 3:10 pm. IDT did not address the day shift falls for Resident 1. The 1:1 for Resident 1 was only for PM and NOC shifts. 2. A review of Resident 2 ' s admission record indicated they were readmitted to the facility 7/03/2021 with diagnoses including unspecified dementia, history of falling, anxiety disorder, and major depression. A review of a fall risk assessment dated [DATE] indicated Resident 2 was a moderate fall risk. A review of a Minimum Data Set (MDS, resident assessment) dated 2/27/2025, indicated Resident 2 was unable to complete Brief Interview for Mental Status (BIMS, a cognitive screening tool) and inability to complete it indicated a significant level of cognitive impairment likely moderate to severe. A review of Resident 2 ' s Fall care plan dated 11/8/25, revised 4/16/25, indicated Resident 2 had an unwitnessed fall and was to have frequent checks. A review of Resident 2 ' s IDT dated 12/24/2024 at 7:53 am, indicated no documentation of date or time of fall. Resident 2 had an unwitnessed fall in their room. Resident 2 was found sitting on the floor on the landing mat next to her bed with her back to the bed. The call light was not pressed. Resident 1 assisted back into their wheelchair with two persons assist. No injuries noted. No complaints of pain or discomfort. New intervention bright neon sign will put to remind Resident 2 to use the call light for assistance (severe cognitive impairment). During an interview on 4/11/2025 at 10:05 am, CNA B stated, Resident 2 was falling a lot before. Not aware of recent falls Falls usually around bathroom. CNA B stated she does not use Point of Care (electronic information about residents) for information about residents fall risk interventions. CNA B stated Resident 2 was unable to use her call light. During an observation on 4/22/2025 at 9:30 am, Resident 2 was asleep with bed in low position. There was a neon sigh posted about her bed that stated, please remember to use call light for assistance. During an interview on 4/22/2025 at 9:35 am, CNA A explained she knew a resident was a high fall risk, when in the room there were devices like fall mat, bed rails, etcetera as a sign of a fall risk. CNA A was observed looking at Resident 2 ' s Point of Care system where CNAs use to view care plans. CNA A stated Resident 2 did not have a fall care plan only one page, the care plan Kardex (lists resident specific care needs) mentioned frequent falls in the middle of a paragraph, with no special instructions to fall risk. CNA A stated, some facilities have star on their room plaque that identifies them as falls risk, not here. Resident 1 ' s care plan had 12 pages, and had no falls listed on Kardex nor care plans for fall risk. During a concurrent interview and record review on 4/22/2025 at 12:20 with the Director of Nursing (DON) confirmed that a reminder to use call light was not an effective intervention for Resident 2 due to her low BIMS severely cognitively impaired. DON confirmed they do not use a falling star or leaf on the name plate or in a residents ' rooms to identify residents to staff that they are a high fall risk and have used it in the past. DON confirmed the IDT can improve on determining the root cause analysis of a fall to develop resident specific interventions for care planning to reduce falls and injuries. DON explained she recently started a binder to collect details about resident falls f to see patterns. DON confirmed having ongoing issues related to resident falls in the facility. DON explained IDT does not include CNAs in developing fall plan of care. DON explained the care plan interventions for Resident 1, frequent checks was not addressed or care planned in the record. DON confirmed no frequency of time given for these frequent checks for Resident 2. DON was not aware that in the Point of Care system the CNAs use only one page of the 12 pages of care plans are visible to the CNAs. DON was not aware of what tools CNAs use to determine a resident is a high fall risk, an issue for registry staff who do not consistently work in the facility. DON confirmed the IDT did not evaluate the effectiveness of the PM and NOC shift 1:1 for Resident 1. DON stated most of his falls were on the evening shift although some were on the day shift. DON confirmed no evaluation of 1:1 effectiveness found in the IDT notes. DON explained the family members will have Resident 1 on a 1:1 when he is home due to his impulsiveness. DON stated she is working on developing and improving the fall program in the facility.

Jan 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to meet this requirement when construction materials were improperly stored in the room of three residents (Residents 2, 3 and 4). This had the potential for accidents and hazards and created an environment that residents did not find home like. Findings: In an interview on 1/13/25 at 9:35 AM, Family Member 1 stated that her mother's room was set up for four residents, but the fourth bed area was taken up by piles of flooring material and adhesive or paint with a privacy curtain pulled around it. She stated that the materials were a tripping and hazard and made it difficult to clean the room thoroughly. In an interview on 1/15/25 at 10:00 AM, Facility Administrator A (FA) A stated that she was familiar with the situation with the storage of materials in room [ROOM NUMBER] of the facility. room [ROOM NUMBER] had been vacant, but then we needed the room and had no place to store the flooring. FA A stated that maintenance stacked the flooring and paint/adhesive cans against the far, windowed portion of the room, and believed that closing the curtain around it was enough to prevent any problems. FA A stated that they had also just received an OSHA (Occupational Safety and Health Administration, assures safe and healthful working conditions), inquiry regarding the incident, and learned it is not ok to store materials there. In an observation on 1/15/25 at 10:20 AM, surveyors observed a pile of approximately two cartons of laminate flooring on sawhorses and approximately 10, 20-gallon buckets of material stacked around them on the resident sidewalk outside room [ROOM NUMBER]. In an interview on 1/15/25 at 10:35 AM, Resident 4 stated that she did see the cans and flooring in her room but the staff removed it. In an interview on 1/15/25 at 10:40 AM, Resident 2 confirmed there had been boxes and cans stored in her room making it stuffy and dusty. In an interview on 1/15/25 at 10:48 AM, Licensed Vocational Nurse (LVN) B stated that a family in room [ROOM NUMBER] brought to her attention that they were concerned about flooring materials that were stored in the room. LVN B stated that they were sealed boxes of laminate flooring and a small package of half-gallon sized paint containers. Nothing was open, she stated, There were no fumes, they were just being stored there. In an interview on 1/15/25 at 12:50 PM, Maintenance Director (MAINT) C stated that there were two types of items being stored in room [ROOM NUMBER]: boxes of flooring and some sealed cans of glue. MAINT C stated that they had never been opened, and he did not feel them to be a hazard at the time. MAINT C confirmed that storing those items there was a bad idea, did not conform to the facility's policy, and that the facility's plan of correction was to move them immediately to a storage shed instead of on the sidewalk outside the room. In an interview on 1/15/25 at 1:00 PM, Resident 3 stated that he was aware there were flooring materials and cans being stored in room [ROOM NUMBER], through the resident council meetings. Review of the facility's policy titled, Receipt and Storage of Supplies and Equipment (undated) indicated, Supplies shall be stored in their designated storage areas; Hazardous/toxic materials must be properly stored and labeled in accordance with current regulations; and It shall be Maintenance's responsibility to ensure that proper storage procedures are maintained.

Oct 2024 16 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of records indicated Resident 40 was admitted in February 2024 with diagnoses of diabetes, epilepsy (seizure disorder), paranoid schizophrenia (a mental illness characterized by disturbances in thought), and anxiety disorder. The MDS indicated Resident 40 had a BIMS score of 15 on 8/23/24, indicating no cognitive (mental function) impairment. MDS also indicated Resident 40's mood was feeling down, depressed, or hopeless two to six days over the last two weeks. During concurrent observation and interview with Resident 40 in their room on 10/1/24 at 2:58 pm, Resident 40 stated HSK A slams the mop on the floor and hits my bed at 7 am with the mop and wakes me up, and, I have to clean my own toilet. Resident 40 stated she had had an episode of diarrhea a while ago, and feces was on the outside of the toilet. Resident 40 stated HSK A, who spoke limited English, came to her room, pointed to the toilet, then pointed at Resident 40 and handed her paper napkins to clean the feces. Observation of Resident 40's bathroom indicated a commode (portable toilet) seat with handles placed over the top of the toilet (allows resident to sit higher over the toilet, decreasing the risk for fall). Resident 40 stated HSK A pointed to the commode indicating Resident 40 was to move the commode to clean the feces. Resident 40 attempted to demonstrate how she moved the commode, became unsteady, and stopped. Resident 40 stated, It's heavy, and I didn't feel well that day from my stomachache and diarrhea. Resident 40 stated she told Family Member B (FM B) about the incident, and FM B brought bottles of Lysol to clean the bathroom. Two bottles of Lysol were observed in Resident 40's closet with one bottle on a shelf outside the bathroom door. Resident 40 stated, I do get paranoid and think, 'Oh no, they don't like me.' During an interview with Housekeeping Manager (HSK M) on 10/3/24 at 8:43 am, HSK M stated Resident 40 informed her, [HSK A] doesn't like me and hits the bed with the mop pole when mopping. Resident 40 informed HSK M she had complained about HSK A to Certified Nurse Assistant J (CNA J) and said to Ask [CNA J]. HSK M stated she changed HSK A's assignment, and HSK A would not be going into Resident 40's room while the incident was being investigated. During an interview with HSK A and HSK M on 10/3/24 at 8:56 am, using phone translation services, HSK A stated she had worked at the facility for 10 years, worked four days a week, and cleaned Resident 40's room when I'm assigned there, approximately twice weekly. HSK A began crying and stated, I never made a mistake like this before. During a phone interview with Admin and CNA J in Admin's office on 10/3/24 at 9:32 am, CNA J stated Resident 40 informed her months ago (did not remember the date) that HSK A wanted Resident 40 to clean the toilet using toilet paper. CNA J stated, [Resident 40] is afraid of [HSK A]. CNA J stated she spoke with HSK A and told HSK A it was her job to clean the toilet, and HSK A said she would not do that again. CNA J stated she did not report the incident to anyone. Admin acknowledged CNA J should have reported the incident to her for investigation. Admin stated she would qualify the outcome as emotional distress for Resident 40. During an interview with Admin on 10/3/24 at 12:47 pm, Admin stated she spoke with Resident 40, who reported the incident occurred in March. Admin stated she called CNA J back to ask when she spoke to the housekeeper; CNA J stated she didn't remember, it was so long ago. A review of Social Services Note, dated 10/3/24 at 6:02 pm, indicated Resident 40 was placed on charting (72-hour monitoring) for emotional distress. The Social Services Director (SSD) stressed to Resident 40 that there was concern for her emotional well-being. A review of letter to State Agency titled 5 Day Investigation by Admin, dated 10/8/24, indicated Resident 40 informed Admin that HSK A asked her to wipe off her toilet after an episode of diarrhea in 3/2024 (six months ago). Resident 40 also informed FM B, who brought Resident 40 cleaning supplies. The letter indicated CNA J stated the incident occurred months ago and that CNA J told the housekeeper not to have the resident wipe the toilet. During an interview with HSK M on 10/8/24 at 11:20 am, HSK M stated the housekeeping company will investigate the abuse allegation. HSK M stated HSK A was suspended pending investigation results, and she was awaiting Admin's paperwork. A review of CNA Job Description, dated 2003, indicated CNAs report all incidents observed on the shift that they occur . report all complaints and grievances made by the resident to the Nurse Supervisor/Charge Nurse . and report all allegations of resident abuse. A review of Patient-Residents' Rights: Abuse-Neglect and The Elder Justice Act Inservice, signed by HSK A and dated 8/28/19, indicated: A. Residents have the right to consideration, dignity, and respect in treatment and care. B. Residents have the right to be free from abuse and must not be subjected to verbal, mental, sexual, or physical abuse by anyone, including facility staff. C. Abuse is defined as the infliction of physical or mental injury . to such an extent that a resident's health, morale, or emotional well-being is endangered. Mental abuse includes but is not limited to humiliation and harassment. A review of CNA/Home Health Aide (HHA) In-Service Training/Continuing Education Units (CEUs), dated 1/26/23 to 1/26/25, indicated CNA J received the following trainings: Your Legal Duty (1/31/24), What is Abuse? (2/1/24), Privacy and Dignity (4/3/24), Preventing Abuse (4/30/24), Abuse and Neglect (8/14/24), and Abuse: Resident to Resident (8/27/24). Based on observation, interview, and record review, the facility failed to ensure two of 22 (Resident 35 and 40) residents were free from abuse and the potential for ongoing abuse when: 1. Certified Nursing Assistant (CNA) E grabbed and held Resident 35's arm when attempting to do personal cares and CNA E continued to be assigned to Resident 35's room after the incident. 2. Housekeeper (HSK) A made Resident 40 clean her own toilet that had feces on it. HSK A continued to be assigned to clean Resident 40's room. This failure caused emotional distress and mental anguish for Resident 35 and Resident 40. Findings: A review of the State Operations Manual (SOM) revised 2/3/23, indicated abuse is defined as the willful (to act deliberately) infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. A review of the facility's policy titled Resident Rights Revised December 2021, indicated Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse A review of the facility's job description titled Certified Nursing Assistant Job Duties and Responsibilities (undated), indicated to Report all allegations of resident abuse And to Honor the resident's refusal of treatment request and report to your supervisor. A review of the facility's policy titled Abuse Prevention Program revised December 2016, indicated As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff 6. Identify and assess all possible incidents of abuse; 8. Protect residents during abuse investigations. 1. A review of Resident 35's admission Record dated 8/27/24, indicated he was re-admitted on [DATE] with the diagnoses that included lung disease, depression, left sided paralysis (unable to move his left arm and leg), adult failure to thrive (the feeling of wanting to give up on life), colostomy (a surgical procedure that redirects the colon to an opening in the abdominal wall in which the feces will exit into a bag), and an indwelling urethral catheter (a tube that goes into the bladder and drains the urine into a collection bag). A review of Resident 35's admission Minimum Data Sheet (MDS, a standardized assessment of an adult's functional, medical, psychosocial, and cognitive status) dated 9/19/24, indicated Resident 35's Brief Interview for Mental Status (BIMS, evaluates a person's cognition, [ability to think, learn, remember, use judgement, and make decisions] with scores from 00 to 15) score was 15 indicating his cognition was intact and he could make his own decisions. Resident 35's level of functioning assessment indicated Resident 35 required full help from staff with toileting hygiene (the ability to clean the bottom after going to the bathroom, adjust clothes before and after urinating or having a bowel movement. If managing an ostomy, include wiping the opening.), upper and lower body dressing, and mobility (moving from his back to his left side or his right). During an observation and interview on 10/1/24 at 2:57 pm, Resident 35 was observed lying in bed with many items (iPad, papers, and other items) on his over bed table and on his bed. Resident 35 stated He (CNA E) grabbed me, he held me down because I took a swing at him. He was messing with my stuff. He was touching my iPad to move it. He would not listen to how I told him to do it. He (CNA E) still comes in my room and leaves the lights on. He is doing it on purpose. I told my nurse about it Resident 35 indicted he was distressed and upset and did not want CNA E to come in his room and was told by a nurse that CNA E would not be coming in this room anymore, but he still was. During an interview on 10/2/24 at 3:40 pm, CNA H indicated that Resident 35 had told him about a staff member that had held him down and was messing with his iPad. During an interview on 10/2/24 at 3:53 pm, the Assistant Director of Nursing (ADON) indicated there had been no report or investigation of a CNA holding down Resident 35. During an interview with the Administrator (Admin) on 10/2/24 at 3:56 pm, the Admin indicated she had not heard of any CNA holding down Resident 35. During an interview with the Admin and CNA E on 10/2/24 at 4:04 pm, CNA E stated I went to check his (Resident 35's) colostomy bag and when I was moving his over bed table, his iPad and other items, he got verbally aggressive and started whacking me. I grabbed his wrist. I should not have grabbed his arm. The second he was getting verbally aggressive I should have left and got the nurse, but I thought I could deescalate the situation. Resident 35 has always been verbally aggressive to me. CNA E indicated that he had notified a charge nurse (unknown) and the Infection Preventionist (IP). CNA E indicated he was told they would switch his resident assignment but that they had not, and he continued being assigned to Resident 35's room. CNA E indicated he had to ask other CNAs to care for Resident 35, but he would still go in the room and care for the other two residents. CNA E indicated that there was one night shift that he had to care for Resident 35 because no other staff member would switch residents with him, and Resident 35 yelled at him. The Admin indicated she was unaware of the incident and had been out of the facility on leave for about 2 weeks in September. During an interview with the IP on 10/2/24 at 4:20 pm, the IP confirmed that CNA E told her that Resident 35 was being aggressive, and she informed him to tell his charge nurse. During an interview with the Director of Staff Development (DSD) on 10/2/24 at 4:25 pm, the DSD confirmed that CNA E had told her about the incident with Resident 35. DSD indicated the incident happened on 9/15/24 during the night shift. DSD indicated she informed the Staffing Coordinator (SC) to change CNA E's assignment. DSD confirmed that there should have been an investigation into this event but there had not been. During a review of the facility's assignment sheets dated 9/15/24 thru 10/1/24, CNA E was assigned to care for Resident 35 on 9/15/24, 9/24/24 thru 9/27/24, 9/30/24, 10/1/24. During an interview on 10/2/24 at 4:33 pm, SC confirmed CNA E was assigned to care for Resident 35 after the incident and he should not have been.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of records indicated Resident 40 was admitted in February 2024 with diagnoses of diabetes, epilepsy (seizure disorder), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder. A review of MDS, dated [DATE], indicated Resident 40 had a BIMS score of 15, indicating no cognitive (mental function) impairment. During concurrent observation and interview with Resident 40 in their room on 10/1/24 at 2:58 pm, Resident 40 stated Housekeeper A (HSK A) slams the mop on the floor and hits my bed at 7 am with the mop and wakes me up, and, I have to clean my own toilet. Resident 40 stated she had had an episode of diarrhea a while ago, and feces was on the outside of the toilet. Resident 40 stated HSK A, who spoke limited English, came to her room, pointed to the toilet, then pointed at Resident 40 and handed her paper napkins to clean the feces. During an interview with Housekeeping Manager (HSK M) on 10/3/24 at 8:43 am, HSK M stated Resident 40 informed her, [HSK A] doesn't like me and hits the bed with the mop pole when mopping. Resident 40 informed HSK M she had complained about HSK A to Certified Nurse Assistant J (CNA J) and said to Ask [CNA J]. During a phone interview with Admin and CNA J in Admin's office on 10/3/24 at 9:32 am, CNA J stated Resident 40 informed her months ago (did not remember the date) that HSK A wanted Resident 40 to clean the toilet using toilet paper. CNA J stated, [Resident 40] is afraid of [HSK A]. CNA J stated she spoke with HSK A and told HSK A it was her job to clean the toilet, and HSK A said she would not do that again. CNA J stated she did not report the incident to anyone. Admin acknowledged CNA J should have reported the incident to her for investigation. Admin stated she would qualify the outcome as emotional distress for Resident 40. During an interview with Admin on 10/3/24 at 12:47 pm, Admin stated she spoke with Resident 40, who informed her the incident occurred in March. Admin stated she called CNA J back to ask when she spoke to the housekeeper; CNA J stated she didn't remember, it was so long ago. During an interview with Resident 40 on 10/3/24 at 2:44 pm, Resident 40 smiled, said Thank you, and stated she was so happy she had a new housekeeper clean her room today. During an interview with HSK M on 10/8/24 at 11:20 am, HSK M stated the Housekeeping company will investigate the abuse allegation. HSK M stated HSK A was suspended pending investigation results, and she was awaiting Admin's paperwork. A review of CNA Job Description, dated 2003, indicated CNAs report all incidents observed on the shift that they occur . report all complaints and grievances made by the resident to the Nurse Supervisor/Charge Nurse . and report all allegations of resident abuse. Based on interview and record review the facility failed to report suspicions and allegations of abuse for three out of five sampled residents (Residents 22, 35, and 40) when: 1. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when CNA M noticed Resident 22 showed fear during care. 2. CNA J did not report an allegation made by Resident 40 that the Housekeeper (HSK) A instructed Resident 40 to clean her own toilet. 3. Facility staff did not report an allegation of staff to resident physical abuse, when CNA E held down Resident 35. The failure to report abuse suspicions and allegations had the potential for residents' to be at risk for staff to resident abuse and had the potential to cause psychosocial harm and negatively impact the resident's overall wellbeing. Findings: A review of the facility's policy and procedures (P&P) titled, Abuse Prevention Program, revised 12/1/16, indicated, the facility would .report any allegations of abuse within timeframes as required by federal requirements. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation revised September 2022, the policy indicated All reports of resident abuse .are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. A review of the undated admission Record, indicated, Resident 22 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (memory loss), chronic pain, and depression. Resident 22 was not her own responsible party (RP, decision maker). A review of Resident 22's Annual Minimum Data Set (MDS, an assessment tool), dated 8/27/24, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) had been performed. Resident 22 had a BIMS of 8, which indicated Resident 22's memory was moderately impaired. A review of Resident 100's undated Admissions Record, indicated, admission to the facility on 5/11/24 with the diagnoses of heart failure and depression. Resident 100 was her own RP. A review of Resident 100's Quarterly MDS, dated [DATE], indicated, Resident 100 had good cognition and a BIMS score of 15. During an interview on 10/1/24 at 11:34 am, Resident 22 stated, the CNAs that worked the night shift handled Resident 22 roughly when providing personal care (repositioning, providing incontinence care). Resident 100 (Resident 22's roommate) stated, witnessing CNAs handle Resident 22 in a rough manner while providing care. During an interview on 10/3/24 at 11:12 am, CNA M stated, Resident 22 had not voiced concerns regarding CNAs being rough during care. CNA M stated, Resident 22 appeared afraid while CNA M had provided personal care in the past and this was a new behavior. CNA M stated, Resident 22 had chronic pain and there was a difference between being afraid of care and having pain during care. CNA M confirmed, having suspicions of potential abuse due to Resident 22's change in behaviors and did not report it to anyone. During an interview on 10/3/24 at 2:42 pm, the facility's Administrator (Admin) stated, when staff suspected abuse, it should be reported and confirmed it was not. 3. A review of Resident 35's admission Record dated 8/27/24, indicated he was re-admitted on [DATE] with the diagnoses that included lung disease, depression, left sided paralysis (unable to move his left arm and leg), adult failure to thrive (the feeling of wanting to give up on life), colostomy (a surgical procedure that redirects the colon to an opening in the abdominal wall in which the bowel will exit into a bag), and an indwelling urethral catheter (a tube that goes into the bladder and drains the urine into a collection bag). A review of Resident 35's admission MDS dated [DATE], indicated Resident 35's BIMS score was 15 indicating his cognition was intact and he could make his own decisions. Resident 35's level of functioning assessment indicated Resident 35 required full help from staff with toileting hygiene (the ability to clean the bottom after going to the bathroom, adjust clothes before and after urinating or having a bowel movement. If managing an ostomy, include wiping the opening.), upper and lower body dressing, and mobility (moving from his back to his left side or his right). During an observation and interview on 10/1/24 at 2:57 pm, Resident 35 was observed lying in bed with many items (iPad, papers, and other items) on his over bed table and on his bed. Resident 35 stated He (CNA E) grabbed me, he held me down because I took a swing at him. He was messing with my stuff. He was touching my iPad to move it. He would not listen to how I told him to do it. He (CNA E) still comes in my room and leaves the lights on. He is doing it on purpose. I told my nurse about it Resident 35 indicted he was distressed and upset and did not want CNA E to come in his room and was told by a nurse that CNA E would not be coming in this room anymore, but he still was. During an interview on 10/2/24 at 3:53 pm, the Assistant Director of Nursing (ADON) indicated there had been no report or investigation of a CNA holding down Resident 35 During an interview with the Admin on 10/2/24 at 3:56 pm, the Admin indicated she had not heard of any CNA holding down Resident 35. During an interview with CNA E and Admin on 10/2/24 at 4:04 pm, CNA E confirmed that he had grabbed Resident's arm while trying to perform cares and he should not have. He indicated that he told the Infection Preventionist (IP) and a charge nurse. The Admin confirmed there was no investigation or report to the local state or federal agencies and there should have been. During an interview with the IP on 10/2/24 at 4:20 pm, the IP confirmed that CNA E told her that Resident 35 was being aggressive, and she informed him to tell his charge nurse. During an interview with the Director of Staff Development (DSD) on 10/2/24 at 4:25 pm, the DSD confirmed that CNA E had told her about the incident with Resident 35. DSD indicated the incident happened on 9/15/24 during the night shift. DSD indicated she informed the Staffing Coordinator (SC) to change CNA E's assignment. DSD confirmed that there should have been an investigation into this event but there had not been.

CONCERN (D)

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

Transfer Requirements (Tag F0622)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure accurate and complete documentation for one of three closed records reviewed when Resident 112 was transferred to an acute care hospital and the facility did not document the date and time of their transfer, where they transferred to, how they were transported, or the disposition of their personal effects and medications. This failure had the potential to negatively impact Resident 112's continuity of care and had the potential risk of them receiving inadequate care or services. Findings: During a review of the facility's policy, titled, Transfer or Discharge Documentation, no revised date provided, indicated: - When a resident is transferred or discharged , details of the transfer or discharge will be documented in the medical record and appropriate information will be communicated to the receiving health care facility or provider. - When a resident is transferred or discharged from the facility, the following information will be documented in the medial record: a. The basis for the transfer or discharge; b. That an appropriate notice was provided to the resident and /or legal representative; c. The date and time of the transfer or discharge; d. The new location of the resident; e. The mode of transportation; f. A summary of the resident's overall medial, physical, and mental conditions; g. Disposition of personal effects; h. Others as appropriate or as necessary; and i. The signature of the person recording the data in the medical record. During a review of Resident 112's clinical record, indicted that Resident 112 was admitted to the facility on [DATE] with diagnoses which included right hip joint replacement surgery, anxiety, and depression. Resident 112 was their own healthcare decision maker. During a review of Resident 112's clinical record, titled, Change in Condition Assessment/SBAR [Situation, Background, Appearance, and Review], dated 7/17/24 at 3:12 pm, indicated that Resident 112 had a change in condition, pain on the right hip and swollen as per resident and assessed by the licensed nurse MD [Medical Director] and RP [Responsible Party] made aware. Pain meds administered as ordered During a concurrent interview and record review on 10/4/24, at 11:42 am, the Director of Nurses (DON) confirmed Resident 112's clinical record did not contain a nursing progress note for transfer to the hospital. The DON further confirmed the nursing progress note was not completed to indicate when resident 112 was transferred to the hospital, how they were transferred or which hospital they were transferred to. The DON stated the documentation should have been completed, the DON said, if the resident was sent out to the hospital, the nursing progress note would have assessment, intervention, and the order of the doctor.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 23 (Resident 101) residents had non-skid footwear on to prevent falls as per his care plan. The facility's lack of safety intervention for Resident 101 had the potential for injury related to unwitnessed falls. Findings: A review of Resident 101's admission Record dated 5/28/24, indicated Resident 101 was admitted to the facility on [DATE] with diagnoses that included stroke (blood flow to the brain is blocked and some brain cells die causing disabilities), muscle weakness, difficulty in walking, and major depressive disorder. A review of Resident 101's Quarterly Minimum Data Set (MDS, a standardized assessment of an adult's functional, medical, psychosocial, and cognitive status) dated 9/4/24, indicated Resident 101's Brief Interview for Mental Status (BIMS, evaluates a person's cognition, [ability to think, learn, remember, use judgement, and make decisions] with scores from 00 to15) score was 07, indicating Resident 101's cognition was severely impaired. Resident 101's Functional Abilities and Goals assessment indicated Resident 101 required maximal assistance from staff for going to the bathroom, upper and lower body dressing, putting on and taking off his footwear, and transferring from a bed to wheelchair (w/c) and back to bed. A review of Resident 101's Fall Care Plan, dated 5/29/24, indicated Resident was at risk for falls related to weakness, poor balance, poor endurance, diagnoses, and history of falls prior to admission. Interventions initiated were to be sure Resident 101's call light was within reach. Anticipate and meet Resident 101's needs. Ensure that Resident 101 was wearing appropriate footwear when out of bed or mobilizing in his wheelchair. During an observation on 10/1/24 at 11:48 am, Resident 101 was observed in his room sitting in his wheelchair wearing only a white tee shirt and briefs (a type of underwear used for incontinence [leakage of urine and bowel]). Resident 101 was attempting to put on his long pants which were on the floor in front of him. He was leaning forward in his wheelchair reaching to the floor with his right hand. He had the waist band in his hand and was struggling to pull the pants on which were stuck on his feet. Resident 101 was in his bare feet. Resident's call light was on the floor. During an observation on 10/1/24 at 11:50 am, Resident 101 was observed in his room. Certified Nursing Assistant (CNA) D entered Resident 101's room and assisted Resident 101 with pulling up his pants. CNA D left the room without putting shoes or socks on Resident 101. During an interview on 10/1/24 at 11:57 am, CNA D acknowledged Resident 101 should have shoes on, but that Resident 101 was not assigned to him that day. CNA D indicated the CNA assigned to Resident 101 was on her brake and when Resident 101 was trying to stand up earlier he went into the room and helped Resident 101 into his chair but did not get him ready for the day because it was not his resident. During an observation and interview on 10/1/24 at 11:59 pm, Resident 101 was observed lying in his bed with his pants on backwards and in his bare feet. Resident 101's call light was on the floor. Resident 101 indicated it was hard to find his call light and that he had to dress himself a lot. Resident 101 indicated he liked to get ready for the day and to have shoes and socks on. Resident 101 indicated he remembered a time he was trying to get up by himself to get ready for the day and he fell and banged his head, and everything hurt. During an interview on 10/3/24 at 3:06 pm, the Director of Staff Development (DSD) indicated Resident 101 should have on non-skid socks or shoes to prevent falls.

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 interview and record review, the facility failed to provide appropriate care for two out of three sampled residents (Residents 87 and 214) with a gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) when: 1. Licensed Nurses (LN) did not follow Resident 87's Physician orders regarding g-tube feeding (Physician prescribed liquid nutrition [formula/feedings] amounts, hydration (free water provided for hydration), water flushes (water flushes aide in keeping the g-tube unclogged and maintained), and inaccurately documented intake amounts. 2. For Resident 87, LNs provided g-tube care without a Physician's order and did not document the care that was provided. 3. Resident 214 received an excessive amount of fluids. These failures placed g-tube residents at risk for fluid overload (too much fluid that placed residents at risk for choking), g-tube malfunction, and had the potential for a decline in health status that could result in hospitalization. Findings: 1. A review of the facility's undated policy and procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, indicated, Licensed Nurses would review the Physician's order prior to administering g-tube feeding and document the amount of g-tube feeding and water flushes that were provided. A review of the undated admission Record, indicated, Resident 87 was admitted to the facility on [DATE] with the diagnoses of malignant neoplasm of tonsil (a type of head and neck cancer), gastrostomy status (g-tube), and dysphagia, oropharyngeal phase (swallowing problems). Resident 87 was his own responsible party (RP, decision maker). A review of Resident 87's Quarterly Minimum Data Set (MDS, an assessment tool), dated 7/8/24, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) had been performed. Resident 87 had a BIMS of 15, which indicated Resident 87's memory was intact. During a concurrent interview and record review on 10/8/24 at 2:58 pm, with LN O Resident 87's Physician's Order (also titled order details), dated 9/24/24, was reviewed along with the Medication Administration Record (MAR), dated 10/1/24 through 10/8/24. LN O stated, the Physician's Order indicated, Resident 87 would receive a total of 2,525 milliliters (ml, unit of measure) of total water intake (amount taken in) from the g-tube feeding and water flushes over a 24-hour period. LN O reviewed the MAR and stated, the MAR indicated, Resident 87 would also receive a 30 ml water flush before and after each medication administration. LN O stated, Resident 87 received medications one time on the am shift for a total of 60 ml of water flushes, two times on the pm shift for a total 120 ml of water flushes, and one time on the night shift for a total of 60 ml of water flushes (a total combined intake total for a 24-hour period, based on Physician orders, was 2,765 ml of g-tube feeding and water). LN O stated, the MAR indicated, Resident 87 received 30 ml of water flushes on each shift and the documentation was incorrectly recorded. LN O stated the documentation for water flushes should have indicated Resident 87 received 120 ml on the pm shift and 60 ml on the am and night shift. LN O reviewed the MAR and stated, the MAR indicated, on 10/1/24, 10/3/24 through 10/5/24, and 10/7/24, LNs documented Resident 87 received, 3,600 ml in a 24-hour period (a total of 835 ml extra fluid), on 10/2/24, Resident 87 received 2,525 ml in a 24-hour period (240 ml less than the Physician ordered), and on 10/6/24, LNs did not document the 24-hour intake total. LN O confirmed, the 24-hour intake totals and the water flush totals did not match the Physician's Order and LNs did not document water flushes correctly. During a concurrent interview and record review on 10/8/24 at 3:57 pm, the Registered Dietician (RD) reviewed the Physician's Order, dated 9/24/24 and stated, the Physician's Order indicated, Resident 87 received 100 ml of tube feeding an hour over 22 hours and the total water volume from the g-tube feeding and the additional water flushes, equaled 2,525 ml. During a concurrent interview and record review on 10/8/24 at 4:11 pm, RD and Director of Nurses (DON) reviewed Resident 87's MAR dated 10/1/24 through 10/8/24. RD and DON confirmed the above calculations regarding Resident 87's total intake, derived from g-tube feedings, water flushes, and water flushes provided before and after medication administration. The RD and the DON confirmed, LN had not been following the Physician's orders and stated, LN had provided too little or too much g-tube feeding. RD and DON confirmed, the above totals for G-tube water flushes, before and after administrations, and stated the MAR indicated LNs were flushing with 30 ml of water with each medication pass and not the Physician ordered 60ml. 2. A review of the facility's undated policy and procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, indicated, LNs would assess the g-tube site for placement (placing a puff of air into the stomach through the g-tube and listening to hear the sound) prior to administering g-tube feeding and document the assessment. A review of the facility's P&P titled Checking Gastric Residual Volume (GRV), revised 11/1/18. Indicated, LNs would ensure there was a Physician's order prior to checking g-tube residuals (stomach contents) and document the amount of residual if any. During a concurrent interview and record review on 10/8/24 at 2:58 pm, Resident 87's Physician Orders, dated 4/1/24 through 10/8/24 was reviewed. LN O stated, prior to administering g-tube feeing, LN O would always check for g-tube placement and residuals. LN O was asked where LN O documented LN O's assessment regarding g-tube placement and residuals. LN O stated, LN O did not document when LN O checked the g-tube for placement or residuals. LN O reviewed Physician's Orders, and stated, the order to check for residuals and g-tube placement was entered into the system, today, 10/8/24. LN O confirmed, LN O had been checking g-tube placement and residuals prior to 10/8/24 without a Physician's Order. During an interview on 10/8/24 at 4:11 pm, DON confirmed there was no order prior to 10/8/24 for LN to check Resident 87's g-tube placement or check for residuals and there should have been. 2. A review of the facility's policy titled Enteral Nutrition (a way of sending nutrition/food directly to the stomach thru a G-Tube) revised November 2018, indicated 3. The dietitian, with input from the provider and nurse: a. estimates calorie, protein, nutrient, and fluid needs. d. Calculates fluids to be provided (beyond free fluids in formula). 11. The nurse confirms that orders for enteral nutrition are complete. Complete orders include . g. instructions for flushing (solution, volume, frequency, timing and 24-hour volume) A Review of Resident 214's admission Record dated 9/16/24, indicated Resident 214 was initially admitted on [DATE], after a hospital stay was readmitted to the facility on [DATE]. Resident 214's diagnoses included Hemiplegia and Hemiparesis (unable to move his left side) following a stroke (blood is blocked from getting to the brain causing cell death), dysphagia (difficulty swallowing), aphasia (difficulty with talking), cognitive communication deficit. A review of Residents 214's 5-day (a review of the first five days in the facility) MDS dated [DATE], indicated his BIMS was 5, indicating Resident 214's cognition was severely impaired. A review of Resident 214's Discharge Summaries Notes from the hospital, dated 9/16/24, indicated orders: Correction diet: Glucerna 1.2 (liquid formula nutrition) at 60 mL an hour. Free water 300 mL every 4 hours. Keep head of the bed elevated more than 30 degrees at all times. Aspiration (fluid or food going into the lungs) precautions. A review of Resident 214's Medical Nutritional Therapy Assessment Recommendations by the Registered Dietitian (RD) dated 9/18/24, indicated recommendations were to change the 9/16/24 order to: 1. Add NPO (nothing by mouth) for diet. 2. Glucerna 1.2 at rate of 75mL an hour x 20 hours to provide 1500 mL of formula, 1800 kcal (kilocalories, measurement of energy), 90 g (grams, a measurement) protein, and 1207 mL free water (the amount of water in the formula). Water flushes 150 mL every 4 hours to provide 900 mL to equal 2107 mL of total water. A review of Resident 214's Physician Order Summary indicated: * An order dated 9/16/24 for Every 4 hours give free water 300 ml. *An order dated 9/18/24 to administer enteral formula every shift: Glucerna 1.2 at a rate of 75 ml an hour, stop at 10:00 am and start at 2:00 pm to provide 1500 mL formula, 1800 kcal, 90 g protein and 1207 ml free water. Water flushes 150 mL every 4 hours to provide 900mL to equal 2107 mL total water (in 24 hours). A review of Resident 214's Medication Administration Record for the month of October 2024, indicated total water ordered for the day was 3907 mL. Which included: *An order for water flushes 300 mL every 4 hours to equal 1800 mL of water. *An order for water flushes 150 mL every 4 hours to equal 900 mL of water *An order for the free water from the formula equaling 1207 mL. A review of Resident 214's progress notes dated 10/7/24 at 6:25 pm, Licensed Nurse (LN) O documented upon assessment found G-Tube formula leaking from tubing Resident sent to ER (emergency room) for further evaluation A review of Resident 214's ER Physician notes dated 10/8/24 at 2:11 am, indicated a target volume (amount of fluid Resident 214 should get in one day) of less than 30 mL/kg (kg a measurement of weight) was to be given due to concern for fluid overload. According to the ER record, Resident 214's weight in the ER was 77.11 kg which would equal 2313.3 mL of fluid in one day. A review of Resident 214's ER visit dated 10/8/24 at 2:34 am, by Supervising Physician (SP) indicated the nurse noticed that the formula was coming out of the patients' mouth, he was coughing and gagging. Assessment of Resident 214 by the SP was aspiration pneumonia (pneumonitis, inflammation of lungs, due to inhalation of food and vomit). During an interview and record review with the RD on 10/8/24 12:26 pm, Resident 214's October 2024 MAR and Physician Orders were reviewed. The RD confirmed Resident 214 was getting over the amount of 2107 mL of water she had recommended. The RD was unaware Resident 214 was getting 3907mL of fluid. The RD indicated Resident 214's admission orders for 300 mL water flushes every 4 hours had not gotten discontinued and it should have been. The RD indicated she usually reviews the orders, but she must have missed this one. During an interview on 10/8/24 12:40 pm, Nurse Practitioner (NP) indicated that 3907 mL was excessive amount of fluid to give Resident 214. NP stated, Yes he is getting too much fluid. During an interview on 10/8/24 at 12:42 pm, the Assistant Director of Nursing (ADON) confirmed that Resident 214 was getting over his recommended amount of water and indicated the order for 300 mL of water every four hours should have been discontinued and it was not.

CONCERN (D)

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

Deficiency F0711 (Tag F0711)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure physician progress notes (doctor's note about resident progress, care, and medical issues) were complete, signed and dated at each visit for for two of four sampled residents (Resident 34, and 98). This failure had the potential to negatively affect communication between disciplines and to result in inappropriate care and service for the residents. Findings: During a review of the facility's job description, titled, Medical Director (MD), revised 10/20, indicated that the MD's duties and responsibilities which included: - Interview residents to obtain history, perform physical examination, order labs, and other tests, prescribe medications and treatments as part of the plan of care. - Provide routine medical care for residents as necessary. - Ensure residents attain or maintain their highest practical physical, mental and psychosocial well-being. During a review of Resident 34's clinical record, indicated that Resident 34 was initially admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), dementia (a progressive state of decline in mental abilities), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). Resident 34 was not his own healthcare decision maker. During a review of Resident 34's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/29/24, indicated Resident 34's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. During a review of Resident 98's clinical record, indicated that Resident 98 was admitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD, also known as kidney failure, is a terminal illness that occurs when the kidneys can no longer function properly), benign neoplasm (benign tumor) on right eyelid, and dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally.) He was his own healthcare decision maker. During a review of Resident 98's MDS, dated [DATE], indicated Resident 98's cognition was intact. During a concurrent observation and interview on 10/1/24 at 11:26 am with Resident 98, Resident 98 's right eye was covered with a gauze. Resident 98 stated, I had been here for over a month, I was waiting for my eye's surgery, they missed it 3 times, and the doctor never came to see me . During an interview on 10/1/24 at 11:30 am with Resident 34, Resident 34 stated, I had been here for 2 years, had never seen the doctor . During a concurrent interview and record review on 10/3/24 at 11:11 am with the Director of Nursing (DON), Resident 34 and 98's clinical record was reviewed. The DON confirmed that she could only locate one physician note for Resident 98, and the note was incomplete, there was no date, no assessment of Resident 98's right eye. The DON also confirmed that there was no physician note in 6/2024, and 9/2024 for Resident 34. The DON stated, I can never read/understand MD's handwritten note. During a concurrent interview and record review on 10/3/24 at 11:15 am with the Medical Record Assistant (MRA), the MRA stated that MD was no longer with the facility, started the end of September 24. MRA stated, our last medical provider had not completed his note, the most recent one was done in 7/2024 We knew the doctor, he did not date, and his note/assessment was not always true, and accurate .

CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. A review of the facility's P&P titled, Abuse Prevention Program, revised 12/1/24, indicated, allegations of abuse would be reported .within timeframes as required by federal requirements. During an interview on 10/1/24 at 11:34 am, Resident 22 stated, the CNAs that worked the night shift handled Resident 22 roughly when providing personal care (repositioning, providing incontinence care). Resident 100 (Resident 22's roommate) stated, witnessing CNAs handle Resident 22 in a rough manner while providing care. During an interview on 10/3/24 at 11:12 am, CNA M stated, Resident 22 had not voiced concerns regarding CNAs being rough during care. CNA M stated, Resident 22 appeared afraid while CNA M had provided personal care in the past and this was a new behavior. CNA M stated, Resident 22 had chronic pain and there was a difference between being afraid of care and having pain during care. CNA M confirmed, having suspicions of potential abuse due to Resident 22's change in behaviors and did not report it to anyone. During an interview on 10/3/24 at 2:42 pm, the facility's Administrator (Admin) stated, when staff suspected abuse, it should be reported and confirmed it was not. 2b. A review of Patient-Residents' Rights: Abuse-Neglect and The Elder Justice Act Inservice, signed by Housekeeper (HSK) A and dated 8/28/19, indicated the purpose of the inservice was to educate employees to residents' rights, resident abuse, and the obligation to report suspected crimes under the Federal Elder Justice Act. The record indicated residents have the right to be free from abuse and to receive consideration, dignity, and respect in treatment and care. A review of records indicated Resident 40 was admitted in February 2024 with diagnoses of diabetes, epilepsy (seizure disorder), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder. Resident 40's MDS indicated Resident 40 had a BIMS score of 15 on 8/23/24, indicating no cognitive (mental function) impairment. During concurrent observation and interview with Resident 40 in their room on 10/1/24 at 2:58 pm, Resident 40 stated, HSK A slams the mop on the floor and hits my bed at 7 am with the mop and wakes me up. Resident 40 stated, I have to clean my own toilet. Resident 40 stated, I do get paranoid and think, 'Oh no, they don't like me.' Resident 40 stated she had had an episode of diarrhea a while ago, and feces got on the outside of the toilet. Resident 40 stated HSK A, who spoke limited English, came to her room, pointed to the toilet, then pointed at Resident 40 and handed her paper napkins to clean it. Observation together of Resident 40's bathroom indicated a commode (portable toilet) seat with handles placed over the top of the toilet (allows resident to sit higher over the toilet, decreasing the risk for fall). Resident 40 stated HSK A had pointed to the commode indicating Resident 40 was to move the commode to clean the feces. Resident 40 attempted to demonstrate how she moved the commode, became unsteady, and stopped. She stated, It's heavy, and I didn't feel well that day from my stomachache and diarrhea. During an interview with Housekeeping Manager (HSK M) on 10/3/24 at 8:43 am, HSK M stated Resident 40 told her, [HSK A] doesn't like me and hits the bed when mopping. HSK M stated Resident 40 complained about HSK A to CNA J and Resident 40 said to ask [CNA J]. HSK M stated she switched HSK A's assignment, and HSK A would not be going into Resident 40's room. During an interview with HSK A and HSK M on 10/3/24 at 8:56 am using phone translation services, HSK A stated she has worked at the facility for 10 years, works four days a week, and is assigned to clean Resident 40's room approximately twice weekly. HSK A began crying and stated, I never made a mistake like this before. During a phone interview with Admin and CNA J in Admin's office on 10/3/24 at 9:32 am, CNA J stated Resident 40 informed her months ago (CNA J could not remember the date) that HSK A wanted Resident 40 to clean the toilet using toilet paper. CNA J stated, [Resident 40] is afraid of [HSK A]. CNA J stated she spoke with HSK A after the incident and told HSK A it was not the resident's job to clean the toilet. CNA J stated, [HSK A] said she would not do that again. CNA J stated she did not report the incident to anyone. After CNA J hung up the phone, Admin acknowledged CNA J should have reported the incident immediately. Admin stated she would qualify the outcome of the incident as emotional distress for Resident 40. A review of 5-Day Investigation by Admin, dated 10/8/24, indicated Resident 40 informed Admin the incident occurred in 3/2024 (six months ago). 2c. A review of records indicated Resident 40 was admitted in February 2024 with diagnoses of diabetes, epilepsy (seizure disorder), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety disorder. A review of MDS, dated 8/23/24, indicated Resident 40 had a BIMS score of 15, indicating no cognitive (mental function) impairment. During concurrent observation and interview with Resident 40 in her room on 10/1/24 at 2:58 pm, Resident 40 stated Housekeeper A (HSK A) slams the mop on the floor and hits my bed at 7 am with the mop and wakes me up, and, I have to clean my own toilet. Resident 40 stated she had had an episode of diarrhea a while ago, and feces was on the outside of the toilet. Resident 40 stated HSK A, who spoke limited English, came to her room, pointed to the toilet, then pointed at Resident 40 and handed her paper napkins to clean the feces. During an interview with Housekeeping Manager (HSK M) on 10/3/24 at 8:43 am, HSK M stated Resident 40 informed her, [HSK A] doesn't like me and hits the bed with the mop pole when mopping. Resident 40 informed HSK M she had complained about HSK A to Certified Nurse Assistant J (CNA J) and said to Ask [CNA J]. During a phone interview with the Administrator (Admin) and CNA J in Admin's office on 10/3/24 at 9:32 am, CNA J stated Resident 40 informed her months ago (did not remember the date) that HSK A wanted Resident 40 to clean the toilet using toilet paper. CNA J stated, [Resident 40] is afraid of [HSK A]. CNA J stated she spoke with HSK A and told HSK A it was her job to clean the toilet, and HSK A said she would not do that again. CNA J stated she did not report the incident to anyone. Admin acknowledged CNA J should have reported the incident to her for investigation. Admin stated she would qualify the outcome as emotional distress for Resident 40. During an interview with Admin on 10/3/24 at 12:47 pm, Admin stated she spoke with Resident 40, who informed her the incident occurred in March. Admin stated she called CNA J back to ask when she spoke to the housekeeper; CNA J stated she didn't remember, it was so long ago. During an interview with Resident 40 on 10/3/24 at 2:44 pm, Resident 40 smiled, said Thank you, and stated she was so happy she had a new housekeeper clean her room today. A review of CNA Job Description, dated 2003, indicated CNAs report all incidents observed on the shift that they occur . report all complaints and grievances made by the resident to the Nurse Supervisor/Charge Nurse . and report all allegations of resident abuse. A review of CNA/Home Health Aide (HHA) In-Service Training/Continuing Education Units (CEUs), dated 1/26/23 to 1/26/25, indicated CNA J received the following trainings: Your Legal Duty (1/31/24), What is Abuse? (2/1/24), Privacy and Dignity (4/3/24), Preventing Abuse (4/30/24), Abuse and Neglect (8/14/24), and Abuse: Resident to Resident (7/25/24, 8/27/24). 3. A review of the facility's undated policy and procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, indicated, Licensed Nurses would review the Physician's order prior to administering g-tube feeding. During a concurrent observation, interview, and record review on 10/8/24 at 2:58 pm, with LN O Resident 87's Physician's Order (also titled order details), dated 9/24/24, was reviewed along with the Medication Administration Record (MAR), dated 10/1/24 through 10/8/24. LN O stated, the Physician's Order indicated, Resident 87 would receive a total of 2,525 milliliters (ml, unit of measure) of total water intake (amount taken in) from the g-tube feeding and water flushes over a 24-hour period. LN O reviewed the MAR and stated, the MAR indicated, Resident 87 would also receive a 30 ml water flush before and after each medication administration. LN O stated, Resident 87 received medications one time on the am shift for a total of 60 ml of water flushes, two times on the pm shift for a total 120 ml of water flushes, and one time on the night shift for a total of 60 ml of water flushes (a total combined intake total for a 24-hour period, based on Physician orders, was 2,765 ml of g-tube feeding and water). LN O stated, the MAR indicated, Resident 87 received 30 ml of water flushes on each shift and the documentation was incorrectly recorded. LN O stated the documentation for water flushes should have indicated Resident 87 received 120 ml on the pm shift and 60 ml on the am and night shift. LN O reviewed the MAR and stated, the MAR indicated, on 10/1/24, 10/3/24 through 10/5/24, and 10/7/24, LNs documented Resident 87 received, 3,600 ml in a 24-hour period (a total of 835 ml extra fluid), on 10/2/24, Resident 87 received 2,525 ml in a 24-hour period (240 ml less than the Physician ordered), and on 10/6/24, LNs did not document the 24-hour intake total. LN O confirmed, the 24-hour intake totals and the water flush totals did not match the Physician's Order and LNs did not document water flushes correctly. LN O was observed reviewing the g-tube feeding totals on the machine (feeding pump) that provided Resident 87 his g-tube feedings. LN O was asked if the feeding pump had the ability to show a history of when the feeding pump was last cleared. LN O stated unawareness and while accessing the screen that indicated how much feeding had been administered, the total was over 3,000 ml. LN O pushed a button and the screen cleared, and stated LN O was unaware of what happened. LN O stated, prior to administering g-tube feeing, LN O would always check for g-tube placement and residuals. LN O was asked where LN O documented LN O's assessment regarding g-tube placement and residuals. LN O stated, LN O did not document when LN O checked the g-tube for placement or residuals. LN O reviewed Physician's Orders, and stated, the order to check for residuals and g-tube placement was entered into the system, today, 10/8/24. LN O confirmed, LN O had been checking g-tube placement and residuals prior to 10/8/24 without a Physician's Order. During a concurrent interview and record review on 10/8/24 at 3:57 pm, the Registered Dietician (RD) reviewed the Physician's Order, dated 9/24/24 and stated, the Physician's Order indicated, Resident 87 received 100 ml of tube feeding an hour over 22 hours and the total water volume from the g-tube feeding and the additional water flushes, equaled 2,525 ml. During a concurrent interview and record review on 10/8/24 at 4:11 pm, RD and Director of Nurses (DON) reviewed Resident 87's MAR dated 10/1/24 through 10/8/24. RD and DON confirmed the above calculations regarding Resident 87's total intake, derived from g-tube feedings, water flushes, and water flushes provided before and after medication administration. The RD and the DON confirmed, LN had not been following the Physician's orders and stated, LN had provided too little or too much g-tube feeding. RD and DON confirmed, the above totals for G-tube water flushes, before and after administrations, and stated the MAR indicated LNs were flushing with 30 ml of water with each medication pass and not the Physician ordered 60ml. A review of the facility's policy and procedure (P&P) titled, Dining and Food Preferences, revised 9/1/17, indicated, resident food preferences would be reviewed, documented, and an alternate meal substitution would be provided. 4. A review of the job duties, titled, Registered Nurse and Licensed Practical (Vocational) Nurse (LPN)/(LVN), revised 5/1/22, indicated, the facility's LN would oversee the CNAs as directed. During an interview on 10/1/24 at 1:25 pm, the facility's Infection Preventionist (IP) stated, when the resident meal trays arrived to the unit, the LN were responsible for checking the resident meal trays prior to the CNA serving the meal to the residents to ensure the meal contained the appropriate diet, utensils, and LN would observe the meal to ensure the food served was not listed on the resident's dislike list. During a concurrent observation and interview, on 10/3/24 at 8:31 am, located in Resident 106's room, there was no breakfast tray present. Resident 106 stated, I was served an egg and cheese omelet this morning and they know I don't like eggs, so I didn't eat it. Certified Nurse Assistant (CNA) B arrived and provided Resident 106 with an alternate breakfast. When CNA B removed the lid from the plate, a piece of bacon and an egg and cheese omelet was observed. CNA B stated unawareness that Resident 106 did not like eggs, CNA B walked to the breakfast tray cart and found Resident 106's original breakfast tray, observed an egg and cheese omelet on the plate, and reviewed the meal tray ticket. CNA B confirmed, the meal tray ticket indicated, Resident 106 disliked eggs, was provided an egg and cheese omelet for breakfast, and the alternate meal provided, consisted of an egg and cheese omelet. During an interview on 10/3/24 at 8:50 am, Licensed Nurse (LN) C stated, the LNs were responsible for performing a visual inspection of the meal trays prior to Certified Nurse Assistant (CNA) serving the residents their meals. LN C stated, the reason the LN's checked the meal trays was to ensure residents received the correct meal texture, the correct adaptive equipment (utensils, plates, cups), and that the meal did not include foods that the resident did not like. LN C stated, being responsible for checking Resident 106's breakfast tray and stated, LN C was in a hurry and did not review the breakfast trays for resident food preferences. LN C confirmed, Resident 106 was served an egg and cheese omelet and did not like eggs. Based on observation, interview, and record review the facility failed to ensure nursing staff demonstrated appropriate skill sets that were required to care for *** out of 22 sampled residents when: 1. Licensed Nurses (LN) did not reassess, notify the Physician, or follow up on Resident 98's potentially infected right eye. 2. LNs and Certified Nurse Assistants (CNA) did not report suspicions or allegations of abuse for Residents 22, 35, and 40. (Refer to F609) 3. LN did not adequately monitor gastrostomy tube (g-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) feedings (liquid hydrations provided through the g-tube) and provided care without a Physician's order. (Refer to F693) 4. LNs did not thoroughly check meal trays to ensure residents received the appropriate food. (Refer to F800) These failures had the potential for hospitalization, and could negatively impact resident's physical, mental, and psychosocial wellbeing. Findings: During a review of the facility's policy, titled, Competency of Nursing staff, revised 5/19, indicated that, Competency in skills and techniques necessary to care for residents' needs includes but is not limited to competencies in areas such as: - Preventing abuse, neglect, and exploitation of resident property. - Dementia management. - Resident rights. - Person centered care. - Communication. - Basic nursing skills. - Basic restorative services. - Skin and wound care. - Pain management. - Infection control - Identification of change in condition - Cultural competency. During a review of the facility's job description, titled, Licensed Practical (Vocational) Nurse (LPN)/(LVN), revised 5/22, indicated that the primary purpose of this position is to provide nursing care to the residents under the supervision of a physician and/or registered nurse and within the scope of nursing practice for the state. Their duties and responsibilities included: - Facilitate physician rounds by preparing carts, flagging areas of concern, and preparing physician orders for signature, document physician visits with residents. - Report any suspicion of a crime that may have been committed to a resident in the facility. - Perform administrative duties by completing medical forms, reports, evaluations, studies, charting, etc. - Assist with resident meals, including delivering meals and helping residents who need help with feeding, as needed. - Provide nursing care that is compassionate and sensitive to residents with cognitive decline, memory loss or history of trauma. - Provide nursing care that is appropriate and sensitive to the culture, language, and background of the resident. - Maintain documentation of all nursing care and services provided to the residents; use nurse's notes, flow sheets and electronic medical records according to facility protocol. - Monitor the skin health of the resident; provide preventative skin care; administer wound treatment as ordered. During a review of the facility's job description, titled, Registered Nurse (RN), revised 5/22, indicated that the primary purpose of this position is to provide nursing care to the residents under the medical direction of the residents' attending physician and within the scope of nursing practice for the state. Their duties and responsibilities included: - Provide oversight of Certified Nursing Assistants (CNAs) and Licensed Nurse (LN) as directed by the Director of Nursing. - Facilitate physician rounds by preparing carts, flagging areas of concern, and preparing physician orders for signature, document physician visits with residents. - Report any suspicion of a crime that may have been committed to a resident in the facility. - Perform administrative duties by completing medical forms, reports, evaluations, studies, charting, etc. - Provide nursing services to residents in accordance with scope of practice, facility policies, and professional standards of care. - Monitor the chronic health conditions of residents; be familiar with reportable changes and potential causes for concern. - Provide nursing care that is compassionate and sensitive to residents with cognitive decline, memory loss or history of trauma. - Provide nursing care that is appropriate and sensitive to the culture, language, and background of the resident. - Maintain documentation of all nursing care and services provided to the residents; use nurse's notes, flow sheets and electronic medical records according to facility protocol. 1. During a review of Resident 98's clinical record, indicated that Resident 98 was admitted on [DATE] with diagnoses which included end stage renal disease (ESRD, also known as kidney failure, is a terminal illness that occurs when the kidneys can no longer function properly), benign neoplasm (benign tumor) on right eyelid, and dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally.) He was his own healthcare decision maker. During a review of Resident 98's MDS, dated [DATE], indicated Resident 98's cognition was intact. During a review of Resident 98's record, titled, admission Skin Assessment, dated 7/30/24, at the section A - Skin, indicated that Resident 98 had Non-pressure skin conditions present, at the section C - Non-Pressure assessment, there's no note or description indicated where the location, and what the assessment was, there's only a note at the Narrative box, indicated that, Skin assessment is done by two LN. Following skin alterations are noted - Skin tear to abdomen (1x2.5 cm); Redness to eye with dressing on. Resident stated it is infected and he is already scheduled for surgery in September . During a review of Resident 98's nursing progress notes from 7/24 to 10/24, there was no note related to Resident 98's right eye to be found. During a concurrent interview and record review on 10/3/24 at 11:11 am with the Director of Nursing (DON), Resident 98's admission record and nursing progress notes were reviewed. The DON confirmed that the admission LN did not assess and document the condition of Resident 98's right eye, and there was no nursing weekly progress note regarding Resident 98's eye assessment, and no note that indicated the nursing staff had notified the MD, and the Scheduler to follow up with Resident 98's right eye appointment and surgery schedule. The DON stated that she would expect the nursing weekly progress note documenting everything regarding Resident 98's right eye condition, such as any redness, discharge, swollen, any pain, was the MD notified, what the order was, etc. The DON also said, When someone had an appointment, we would have the Scheduler arranged the appointment and transportation for Resident 98. We would honor it, and the Interdisciplinary team (IDT - a gathering of healthcare providers from different disciplines to coordinate care for a patient) meeting would be discussing it. During an interview with on 10/4/24 at 3:40 pm with the Scheduler, the Scheduler stated that the nurse who did the initial assessment should have communicated with her and notified her about Resident 98's scheduled appointment for the surgery, she would try to contact the provider and arrange the transportation for the resident.

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 observation, interview, and record review, one of 22 sampled residents (Resident 61) failed to be free of unnecessary psychotropic medications when Resident 61 had a routine Ativan (anti-anxiety medication) order of 0.5 milligrams (mg - a unit of measure) and a pro re nata (PRN - as needed) order for Ativan 0.5 mg. The PRN Ativan order was available for five months without an order end date despite Consulting Pharmacist (CPH) recommendations to discontinue the PRN order or limit the order to 14 days per Centers for Medicare and Medicaid Services (CMS - a federal entity that works to improve the quality of healthcare) regulations. Psychotropic medications affect brain activities associated with mental processes and behaviors and include anti-psychotic, anti-depressant, anti-anxiety and hypnotic (sedating) medications. This deficient practice had the potential for Resident 61 to experience adverse (negative, potentially harmful) side effects from excessive or unnecessary psychotropic medications including sedation, falls, abnormal involuntary movements, stroke, and death. Findings: A review of Policy and Procedure (P&P) titled Medication Monitoring, Medication Management, dated 1/2022, indicated: 1. The facility must ensure PRN orders for psychotropic drugs are limited to 14 days, without exception. PRN orders cannot be renewed unless the attending physician directly examines the resident to determine if the antipsychotic is still needed on a PRN basis, evaluates the benefits of the medication, and determines if expressions or indications of distress are improved as a result of the PRN medication. The intent of this requirement is that PRN psychotropic medication orders are only used when the medication is necessary and PRN use is limited. 2. The facility must rule out other causes of distress such as pain and environmental factors such as staffing levels, overstimulation, and noise levels. 3. The facility assures that residents are monitored for potential adverse effects such as falls, shortness of breath, increased blood pressure, weight loss/gain, agitation, distress, tardive dyskinesia (involuntary movements), and stroke. If adverse effects are identified, the facility and prescriber must determine if the medication should be continued and document the rationale for the decision. A review of P&P titled Dementia - Clinical Protocol, dated 11/2018, indicated: 1. The physician will help identify individuals who have been diagnosed with dementia and those with otherwise impaired cognition (mental processing). 2. The Interdisciplinary Team (IDT - a team with members from different disciplines who work together to set resident goals and make care decisions) evaluates and helps identify symptoms and findings that differentiate dementia from other causes. 3. The physician and staff will review the effectiveness and complications of medications and will adjust, stop, or change such medications as indicated. A review of records indicated Resident 61 was a [AGE] year-old admitted in March 2021 with diagnoses of alcoholic hepatitis (a life-threatening liver condition caused by heavy alcohol use), chronic kidney disease, anxiety disorder, and chronic pain. Resident 61 was later diagnosed with schizoaffective disorder - bipolar type (disrupted thoughts and perceptions, extreme mood swings) on 5/25/21, after-effects of stroke on 9/29/22, and unspecified dementia (decline in thought processes, memory, and reasoning) with psychotic disturbance on 4/24/24. The record indicated Resident 61 was unable to make their own healthcare decisions. A review of Minimum Data Set (MDS - a tool used to assess and manage care of residents in nursing homes), dated 7/7/24, indicated Resident 61's score was 8 out of 15 on Brief Interview for Mental Status (BIMS - an assessment tool to screen mental status), demonstrating moderate to severe cognitive (mental function) impairment. The MDS indicated Resident 61 had little interest in doing things and feeling down two to six days over the last two weeks. MDS indicated Resident 61 was taking antipsychotic, antianxiety, antidepressant, opioid (pain medication), and antiplatelet (prevents blood clots) medications. A review of Care Plans, printed 10/3/24, indicated: 1. Initiated 3/31/21, revised 7/16/24: Resident 61 uses Ativan for anxiety manifested by (m/b) shortness of breath and Lexapro for anxiety m/b agitation. Interventions include administering anti-anxiety medications, monitoring for side effects and effectiveness, IDT review of medications quarterly and as needed, monitoring Resident 61 for safety due to increased risk of cognitive impairment and falls, monitoring for adverse effects including aggressive or impulsive behaviors, and monitoring/recording excessive verbalization of worry. 2. Initiated 5/29/21, revised 7/16/24: Resident 61 is on Seroquel for schizoaffective disorder m/b angry aggressive behavior towards others and Rexulti for dementia with psychotic disturbance m/b episodes of agitation. Interventions include administering psychotropic medications, consult pharmacist/MD to consider dose reduction when appropriate at least quarterly, IDT to review medications quarterly and as needed, monitor for adverse effects of psychotropic medications including falls and weight loss, and monitor/record behavior symptoms of angry aggressive behavior towards others and agitation. 3. Initiated 4/5/24: Resident 61 is on Ativan related to aggressive behaviors. Interventions included administering Ativan PRN, monitoring behaviors every shift and tally, monitoring for adverse reactions/side effects of Ativan, notifying MD if worsening, and providing redirection and other non-medication interventions. A review of Risk versus (v.) Benefits IDT Review for Gradual Dose Reduction (GDR), dated 4/24/24, indicated the Current Psychotropic Regimen included Seroquel 50 mg, two tablets by mouth twice a day, for schizophrenia as evidenced by angry aggressive behaviors towards others, and buspirone hydrochloride (anti-anxiety medication) 10 mg, 1 tablet by mouth three times a day, for anxiety disorder m/b uncontrollable motor movements. IDT recommended adding Rexulti 2 mg daily for episodes of agitation with behavior monitoring and review in one month. Ativan was not addressed in the record. A review of Consultant Pharmacist's (CPH) Medication Regimen Review by CPH A, dated 4/29/24, indicated Resident 61 had a PRN order for Ativan. CPH A documented that CMS regulations limit all PRN psychotropic medications to 14 days unless the prescriber specifies an end-date duration. CPH A recommended the prescriber discontinue PRN Ativan or add an end date to the order. A review of three records titled IDT Psychotherapeutic Tally and Review (PT&R), dated 6/17/24, 7/15/24, and 8/20/24, indicated the following: A. Behavior tallies (nursing documentation of behaviors): 1. Angry aggressive behavior towards others: March 105, April 123, May 56, June 53, July 47. 2. Verbalization of anxiousness: April 132, May 109. 3. Shortness of breath: April 132, May 109, June 57, July 50. 4. Psychotic disturbance as evidenced by agitation: April 12, May 41, June 77. 5. Verbalization of health concerns: May 41, June 84, July 78. B. The 6/17/24 IDT PT&R indicated previous recommendations and plan were to discontinue Rexulti, add escitalopram 10 mg daily for anxiety m/b agitation, and increase Seroquel to 200 mg twice a day, with review in one month. The record indicated escitalopram (antidepressant) was started 5/22/24 for depression m/b verbalization of health concerns. IDT Note and Recommendations from meeting on 6/19/24: Reviewed current tallies and medications with IDT. Plan to increase Rexulti to 3 mg, update escitalopram monitoring, and update Ativan PRN m/b to shortness of breath (SOB), with review during next psych meeting. C. The 7/15/24 IDT PT&R indicated gradual dose reduction to begin 7/17/24 for Rexulti: give 2 mg for one week, then 1 mg for one week, then discontinue. IDT Note and Recommendations from meeting on 7/17/24: Tallies and medications reviewed by IDT team. Plan to GDR Rexulti and continue other medications with no change, with review during next psych meeting. D. The 8/20/24 IDT PT&R indicated IDT Note and Recommendations from meeting on 8/28/24: Tallies and medications reviewed. No changes recommended at this time. A review of CPH Medication Regimen Review by CPH A, dated 7/1/24, indicated Resident 61 was at increased risk of serotonin syndrome toxicity (a potentially life-threatening drug reaction) while on a combination of Lexapro (antidepressant), Ativan, Seroquel, and Rexulti (antipsychotic medication). The record indicated the risk of serotonin syndrome toxicity may be increased when Ativan, Seroquel, and Rexulti are administered together. CPH A recommended monitoring closely for symptoms of toxicity and consider alternatives to the current regimen. A review of two CPH Medication Regimen Reviews by CPH A, dated 8/2/24 and 8/29/24, indicated Resident 61 had a PRN order for Ativan. CPH A documented that CMS regulations limit all PRN psychotropic medication use to 14 days and cannot be continued unless the prescriber evaluates the resident for appropriateness and documents rationale for continuation. CPH A recommended the prescriber discontinue PRN Ativan or add an end date to the order. During an interview with Social Services Assistant (SSA) on 10/8/24 at 11:41 am, SSA stated Resident 61 has had four unwitnessed falls in the last two months. SSA stated Resident 61 has been more independent in a wheelchair recently, wheeling herself throughout the facility. SSA stated Resident 61 will get worked up like it's the end of the world. SSA stated yelling and calling out is present but is less. During an interview with Director of Nursing (DON) on 10/8/24 at 10:32 am, DON stated IDT psychotropic medication reviews occur the third Wednesday of each month with CPH A and CPH B. DON stated medication recommendations are received from CPH A the first week of each month for the previous month, but September wasn't done yet. DON stated this was because state survey started, and the facility had a change of medical director effective 10/1/24. DON stated IDT evaluates behaviors from nursing documentation of behavior tallies during medication regimen review, and then pharmacists and the medical director evaluate medication dosages and make changes as needed. During an interview with CNA P on 10/8/24 at 12:26 pm, CNA P stated Resident 61 has behaviors every day, but not as bad as it was, noting Resident 61 is verbally aggressive with staff. CNA P stated, [Resident 61] will ask for a pain pill. If the nurse isn't 'fast enough,' she'll call the nurse a f***ing b*tch. During an interview with CNA N on 10/8/24 at 12:48 pm, CNA N stated Resident 61 shows aggressive verbal behaviors mostly daily. CNA N stated Resident 61 will cuss you out, call you names. CNA N stated she usually tells the nurse about these behaviors but does not typically document it in the medical record because it's daily and expected behavior. During a concurrent interview with Social Services Director (SSD) and SSA and record review on 10/8/24 at 3:48 pm, SSD stated she participates in monthly Medication Regimen Reviews as part of the IDT team. SSD stated she prepares a list for review for each resident to be reviewed and confirms tallies (behavior monitor counts) are correct. SSA stated Resident 61 had anxiety on admission, was initially able to go out for smoke breaks, but then had a change to more aggressive behaviors. SSD reviewed records and stated the physician was notified 10/5/22 that Resident 61's Patient Health Questionnaire-9 (PHQ9 - a depression questionnaire) triggered for depression. SSD stated IDT had been meeting monthly for the past year to evaluate Resident 61's medication regimen. SSD stated Resident 61 is more needy now, was not like that before, and has been calling out for help now. During a concurrent interview with CPH B and record review on 10/08/24 at 4:05 pm, CPH B stated he had been a pharmacist for 30 years. CPH B stated he had been the consulting pharmacist for the facility for two years when CPH A took over about a year ago. CPH B reviewed records on his computer and stated Resident 61 had a scheduled (routine) Ativan order and a PRN (as needed) Ativan order. CPH B stated the PRN Ativan 0.5 mg order was in place in 4/2024 at the time CPH A recommended the PRN order be discontinued or an order end-date be added. CPH B stated the PRN Ativan order was not discontinued until 8/12/24 (four months later). However, CPH B stated a new PRN Ativan 0.5 mg order was started the same day, 8/12/24, and was not discontinued until 9/11/24 (30 days later). CPH B acknowledged PRN Ativan was ordered for greater than 14 days, which was not appropriate without a Benefits v. Risks (BVR) Review with physician documentation for reasons to continue the PRN Ativan and a recommendation for duration of therapy. CPH B stated CPH A requested a BVR from the physician on 8/2/24, but he did not see a completed BVR after that date. CPH B stated CPH A had also requested a gradual dose reduction of the routine scheduled Ativan on 8/29/24. CPH B stated an order was placed 4/26/24 for Ativan 0.5 mg three times a day (every 8 hours) until 9/6/24 when the order was changed to twice a day (every 12 hours). CPH B stated Resident 61 received three doses of Ativan 0.5 mg (scheduled) and an additional Ativan 0.5 mg (PRN) on 5/23/24 for a total of 2 mg in 24 hours. CPH B stated 2 mg was the maximum (max) recommended dose without a BVR Review by the physician. CPH B stated medication administration records indicated the following: 1. In June 2024, all scheduled Ativan was given three times a day as ordered; an additional four doses of PRN Ativan were given on 6/8, 6/9, 6/13, and 6/14/24. 2. In July 2024, all scheduled Ativan was given three times a day as ordered; an additional two doses of PRN Ativan were given 7/7 and 7/16/24. 3. In August 2024, all scheduled Ativan was given three times a day as ordered; no PRN doses were given. A review of drug information for Ativan on [NAME]-Drug (a drug reference platform that provides information to help medical professionals make evidence-based drug decisions) on 10/15/24 indicated Ativan should be avoided or dose reduced in patients who are receiving opioids or have significant chronic disease. Ativan should be avoided in residents with a history of substance use or depression except for acute or emergent situations like acute agitation or status epilepticus (seizures). Ativan is a high-risk medication and should be avoided in adults aged 65 and older due to increased risk of impaired mental functioning, delirium, falls, and fractures (broken bones). Use of benzodiazepines (drug class) like Ativan is not recommended for greater than or equal to four weeks. Use of Ativan in patients with impaired kidney and liver function may worsen hepatic encephalopathy (a brain disorder that occurs when the liver is unable to remove toxins from the blood, causing them to build up in the brain and impact brain function).

CONCERN (D)

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

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility's policy and procedure (P&P) on dental services was followed for one of 22 sampled residents (Resident 35). This failure had the potential to result in Resident 1's weight loss due to difficulty eating. Findings: A review of the facility policy titled Dental Examination/Assessment revised December 2013, indicated Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. A review of Resident 35's admission Record dated 8/27/24, indicated he was re-admitted on [DATE] with the diagnoses that included lung disease, depression, left sided paralysis (unable to move his left arm and leg), adult failure to thrive (the feeling of wanting to give up on life), colostomy (a surgical procedure that redirects the colon to an opening in the abdominal wall in which the bowel will exit into a bag), and an indwelling urethral catheter (a tube that goes into the bladder and drains the urine into a collection bag). During a concurrent observation and interview of Resident 35 on 10/1/24 at 3:02 pm, Resident 35 was observed in his room lying in bed. Resident had no teeth in his mouth. Resident 35 stated They (a dentist that came to the facility) pulled them out and now they say they cannot give them (dentures) to me because I do not have insurance. I was eating good with the teeth I had in my mouth, now I cannot chew the bread it is too hard. During an interview on 10/03/24 at 11:36 am, the Social Service Director (SSD) indicated Resident 35 had his teeth extracted on December 8, 2023, by a facility contracted dental service, and impressions and x-rays were done on January 12, 2024. During an interview on 10/3/24 at 11:37 am, the Social Service Assistant (SSA) indicated Resident 35's insurance plan had changed, and the contracted dental services will not honor the new insurance. A review of Resident 35's dental notes from (Dental Name) Healthcare dated 12/08/23, showed Resident 35 had 4 teeth extracted. A review of Resident 35's dental notes from (Dental Name) Healthcare dated 1/12/24, showed Resident 35 had upper and lower impressions taken for new dentures. A review of Resident 35's Care Conference dated 6/2/24, showed notes written by the SSD Daughter also asks that we follow up with his dentures. A review of an e-mail by a Patient Care Coordinator (PCC) from (Dental Name) Healthcare dated 6/13/24, indicated I have called a couple of times to discuss a couple of patients that their denture process is on hold due to their (insurance name). During an interview on 10/3/24 at 1:56 pm, the SSD indicated she had not called the contracted dental services to follow up on Resident 35 dentures until his daughter brought it up at the care conference 5 months after he had his teeth pulled and impressions done. The SSD indicated that she should have followed up on it.

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** 5. During an interview with Resident 104 on 10/2/24 at 10:26 am, Resident 104 stated, Yuck, when asked about the food served in the facility. Resident 104 stated they often request hamburgers and hot dogs rather than the meals offered and that the vegetables are always overcooked. Resident 104 stated they do not want carrots, peas, or corn but, I'm always getting those. Resident 104 also stated kitchen staff chop the spinach too small and overcook it. A review of Resident 104's Thursday Breakfast and Thursday Lunch food tray tickets, dated 10/3/24, indicated dislikes include carrots, corn, peas, and spinach. During an interview with Dietary Manager (DM) on 10/2/24 at 5:53 am, DM stated she and Registered Dietitian (RD) work together to ask residents their food preferences. DM acknowledged two (unnamed) residents complained about receiving foods on their dislikes lists on 10/1/24, and the residents should not have received those items. DM stated, Corporate controls what options are available, noting one resident likes lettuce but not tomatoes, but lettuce and tomato are together on the preference list. DM acknowledged a resident whose documented dislikes included no fish groups should not have received a tuna sandwich on 10/1/24, and the other resident should not have been served a tomato on her sandwich but the kitchen was rushed with State [surveyors] present in the building. Based on observation, interview, and record review, the facility failed to honor food preferences for five out of 22 sampled residents (Residents 46, 90, 100, 104, and 106) when: 1. Resident 46 received eggs for breakfast. 2. Resident 90 received rice with meals. 3. Resident 100 received tomatoes with a salad. 4. Resident 106 received eggs for breakfast and a tuna fish sandwich for lunch. 5. Resident 104 received carrots, peas, and corn with meals. This failure had the potential to negatively impact psychosocial health and cause weight loss. Findings: 1. A review of the facility's policy and procedure (P&P) titled, Dining and Food Preferences, revised 9/1/17, indicated, resident food preferences would be reviewed, documented, and an alternate meal substitution would be provided. A review of the Resident Council meeting notes, dated 7/23/24, indicated, food complaints from the previous meeting held in June, had not been resolved. The meeting notes did not indicate, what the food complaints were. During a review of the undated, COVID-19 Resident Satisfaction Survey, that was provided with Resident Council meeting notes, dated 9/24/24, indicated, the food could use some help. The document did not indicate what the food complaint was. A review of the undated Admissions Record, indicated, Resident 46 was admitted to the facility on [DATE] with the diagnoses of type 2 diabetes (inability to regulate blood sugar levels because the body didn't produce enough insulin) and anxiety. Resident was her own responsible party (RP, made own decisions) A review of Resident 46's Quarterly Minimum Data Set (MDS, an assessment tool), dated 9/17/24, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) had been performed. Resident 46 had a BIMS of 15, which indicated good memory. During an interview on 10/2/24 at 8:38 am, Resident 46 stated, the food that was served in the facility was a work in progress. Resident 46 stated, in the past, Resident 46 reported the dislike of eggs to an unknown female staff member and continued to receive eggs for breakfast. A review of Resident 46's Dietary Profile dated 9/18/24, did not include eggs as a dislike. 2. A review of the undated Admissions Record, indicated Resident 90 was admitted to the facility on [DATE] with the diagnoses of type 2 diabetes and high blood pressure. Resident 90 was his own RP. A review of Resident 90's Quarterly MDS, dated [DATE], indicated, Resident 90 had good cognition and a BIMS score of 15. During an interview on 10/2/24 at 11:02 am, Resident 90 stated, the facility did not honor food preferences. Resident 90 stated having a dislike of rice and was served rice often. A review of Resident 90's Dietary Profile, dated 1/24/24, 4/24/24, and 7/18/24, indicated, Resident 90 did not like rice. 3. A review of Resident 100's undated Admissions Record, indicated, admission to the facility on 5/11/24 with the diagnoses of heart failure and depression. Resident 100 was her own RP. A review of Resident 100's Quarterly MDS, dated [DATE], indicated, Resident 100 had good cognition and a BIMS score of 15. During an interview on 10/1/24 at 11:24 am, Resident 100 stated, the food is terrible, I don't eat tomatoes, and they always serve me tomatoes. Resident 100 stated, when you complain about the food, the food is worse, like they intentionally give us food we don't like. During a concurrent observation, interview, and record review, on 10/1/24 at 1:25 pm, Resident 100's lunch tray was observed. Resident 100 stated, there were tomatoes served with lunch. A salad that contained pieces of cut up tomatoes was observed next to a meal tray ticket. The meal tray ticket, dated 10/1/24, indicated, Resident 100 disliked tomato products. The facility's Infection Preventionist (IP) was unaware which staff member had checked the resident's meals for accuracy and confirmed, Resident 100 disliked tomatoes and confirmed Resident 100 received tomatoes with her lunch. 4. A review of the undated admission Record, indicated, Resident 106 was admitted to the facility on [DATE] with the diagnosis of dysphagia following nontraumatic intracerebral hemorrhage (bleeding in the brain that caused difficulty with swallowing and was not caused by injury). Resident 106 was not her own responsible party (did not make own decisions). A review of Resident 106's Quarterly MDS, dated [DATE], indicated, Resident 106 had a BIMS score of 3, which indicated poor memory. During an interview on 10/1/24 at 12:35 pm, Resident 106 stated, the food was bad, did not eat the amount of food that Resident 106 would normally eat, felt worthless, and began to cry. During a concurrent observation and interview on 10/1/24 at 1:33 pm, Resident 106 was observed eating fast food with family member (FM). Resident 106 stated, lunch was horrible. FM stated, FM brought food to Resident 106 due to not liking the lunch that was served. Resident 106 stated, lunch was a tuna fish sandwich and disliked tuna. During a concurrent observation and interview with the facility's Director of Staff Development (DSD), the cart that contained resident meal trays was observed. DSD found the lunch tray that was served to Resident 106. DSD stated, the meal tray ticket, dated 10/1/24, located on the meal tray, indicated, Resident 106 disliked fish and confirmed, Resident 106 was served a tuna fish sandwich for lunch. During a concurrent observation and interview, on 10/3/24 at 8:31 am, located in Resident 106's room, there was no breakfast tray present. Resident 106 stated, I was served an egg and cheese omelet this morning and they know I don't like eggs, so I didn't eat it. Certified Nurse Assistant (CNA) B arrived and provided Resident 106 with an alternate breakfast. When CNA B removed the lid from the plate, a piece of bacon and an egg and cheese omelet was observed. CNA B stated unawareness that Resident 106 did not like eggs, CNA B walked to the breakfast tray cart and found Resident 106's original breakfast tray, observed an egg and cheese omelet on the plate, and reviewed the meal tray ticket. CNA B confirmed, the meal tray ticket indicated, Resident 106 disliked eggs, was provided an egg and cheese omelet for breakfast, and the alternate meal provided, consisted of an egg and cheese omelet. During an interview on 10/3/24 at 8:50 am, Licensed Nurse (LN) C stated, the LNs were responsible for performing a visual inspection of the meal trays prior to the resident being served their meals. LN C stated, the reason the LN's checked the meal trays was to ensure residents received the correct meal texture, the correct adaptive equipment (utensils, plates, cups), and that the meal did not include foods that the resident did not like. LN C stated, being responsible for checking Resident 106's breakfast tray and stated, LN C was in a hurry and did not review the breakfast trays for resident food preferences. LN C confirmed, Resident 106 was served an egg and cheese omelet and did not like eggs. During a concurrent interview and record review on 10/3/24 at 9:16 am, with Certified Dietary Manager (CDM) and Dietary Manager (DM), photos of Resident 106's breakfast and alternate breakfast were reviewed. CMD and DM confirmed, Resident 106 was served an egg and cheese omelet for breakfast and as an alternate meal. CDM and DM acknowledged there were resident concerns regarding food preferences not being honored.

CONCERN (E) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Patient-Residents' Rights: Abuse-Neglect and The Elder Justice Act Inservice, signed by Housekeeper (HSK) A and dated 8/28/19, indicated the purpose of the in-service was to educate employees to residents' rights, resident abuse, and the obligation to report suspected crimes under the Federal Elder Justice Act. The record indicated residents have the right to be free from abuse and to receive consideration, dignity, and respect in treatment and care. A review of records indicated Resident 40 was admitted in February 2024 with diagnoses of diabetes, epilepsy (seizure disorder), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety disorder. Resident 40's MDS indicated Resident 40 had a BIMS score of 15 on 8/23/24, indicating no cognitive (mental function) impairment. During concurrent observation and interview with Resident 40 in their room on 10/1/24 at 2:58 pm, Resident 40 stated, HSK A slams the mop on the floor and hits my bed at 7 am with the mop and wakes me up. Resident 40 stated, I have to clean my own toilet. Resident 40 stated, I do get paranoid and think, 'Oh no, they don't like me.' Resident 40 stated she had had an episode of diarrhea a while ago, and feces got on the outside of the toilet. Resident 40 stated HSK A, who spoke limited English, came to her room, pointed to the toilet, then pointed at Resident 40 and handed her paper napkins to clean it. Observation together of Resident 40's bathroom indicated a commode (portable toilet) seat with handles placed over the top of the toilet (allows resident to sit higher over the toilet, decreasing the risk for fall). Resident 40 stated HSK A had pointed to the commode indicating Resident 40 was to move the commode to clean the feces. Resident 40 attempted to demonstrate how she moved the commode, became unsteady, and stopped. She stated, It's heavy, and I didn't feel well that day from my stomachache and diarrhea. During an interview with Housekeeping Manager (HSK M) on 10/3/24 at 8:43 am, HSK M stated Resident 40 told her, [HSK A] doesn't like me and hits the bed when mopping. HSK M stated Resident 40 complained about HSK A to CNA J and Resident 40 said to ask [CNA J]. HSK M stated she switched HSK A's assignment, and HSK A would not be going into Resident 40's room. During an interview with HSK A and HSK M on 10/3/24 at 8:56 am using phone translation services, HSK A stated she has worked at the facility for 10 years, works four days a week, and is assigned to clean Resident 40's room approximately twice weekly. HSK A began crying and stated, I never made a mistake like this before. During a phone interview with Admin and CNA J in Admin's office on 10/3/24 at 9:32 am, CNA J stated Resident 40 informed her months ago (CNA J could not remember the date) that HSK A wanted Resident 40 to clean the toilet using toilet paper. CNA J stated, [Resident 40] is afraid of [HSK A]. CNA J stated she spoke with HSK A after the incident and told HSK A it was not the resident's job to clean the toilet. CNA J stated, [HSK A] said she would not do that again. CNA J stated she did not report the incident to anyone. After CNA J hung up the phone, Admin acknowledged CNA J should have reported the incident immediately. Admin stated she would qualify the outcome of the incident as emotional distress for Resident 40. A review of 5-Day Investigation by Admin, dated 10/8/24, indicated Resident 40 informed Admin the incident occurred in 3/2024 (six months ago). Based on observation, interview, and record review, the facility failed to ensure that six out of 22 sampled residents (Residents 40, 46, 90, 100, 101, and 106) was treated with dignity and respect when: 1. Facility staff did not speak English in front of Residents 46, 90, and 100. 2. The night shift was loud. 3. Resident 101 was not provided privacy during personal care. 4. Resident 40 was instructed to clean her own toilet. This had the potential for residents to not have their right for dignity, respect, and negatively impact resident's physical, mental, and psychosocial wellbeing. Findings: 1. A review of the undated document titled English Only Rule, indicated, it was the facility's policy that staff only spoke English . in resident rooms . and in any area of the facility that a resident could hear staff speaking. The English Only Rule, indicated, a violation of this policy was a violation of resident rights and that when staff signed the document, they understood, speaking in a language the resident did not understand could cause fear, confusion, and disturb residents. A review of the facility's policy and procedure (P&P) titled Resident Rights, revised 12/1/21, indicated, Employees shall treat all residents with kindness, respect, and dignity. A review of the Resident Council (an organized group of residents that met regularly to discuss and address concerns regarding their rights) meeting notes, dated 7/23/24, indicated, residents of the facility voiced concerns when facility staff did not speak English in their rooms, the hallways, and at the nurse's station. A review of the Resident Compliment or Concern document, dated 7/23/24, indicated, the Director of Staff Development (DSD) provided education to facility staff regarding the facility policy for speaking English and the issue was resolved on 8/7/24. A review of Resident 46's undated admission Record, indicated, admission to the facility on 6/6/24 with the diagnoses of anxiety and type 2 diabetes (inability to regulate blood sugar levels because the body didn't produce enough insulin). Resident 46 was her own responsible party (RP, made own decisions). A review of Resident 46's Quarterly Minimum Data Set (MDS, an assessment tool), dated 9/17/24, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) had been performed. Resident 46 had a BIMS of 15, which indicated good memory. During an interview on 10/2/24 at 8:38 am, Resident 46 stated, staff spoke their native language in front of the residents. Resident 46 stated, when a group of staff (two or more that included Certified Nurse Assistants [CNA], Licensed Nurses [LN], or housekeepers) came into the room to provide care, they did not speak English in front of us. Resident 46 stated, I feel like they are talking about us, It bothers me, and I don't feel comfortable. A review of the undated Admissions Record, indicated Resident 90 was admitted to the facility on [DATE] with the diagnoses of type 2 diabetes and high blood pressure. Resident 90 was his own RP. A review of Resident 90's Quarterly MDS, dated [DATE], indicated, Resident 90 had good cognition and a BIMS score of 15. During an interview on 10/2/24 at 10:03 am, Resident 90 stated, when there were groups of staff in the room, hallway, or in front of other residents, they did not speak English. Resident 90 stated, during the morning, a group of female staff members were talking in the hallway, speaking their native language, and turned their backs to Resident 90 and would look back towards Resident 90. Resident 90 stated, I know they talk about me, it was frustrating and disrespectful. A review of Resident 100's undated Admissions Record, indicated, admission to the facility on 5/11/24 with the diagnoses of heart failure and depression. Resident 100 was her own RP. A review of Resident 100's Quarterly MDS, dated [DATE], indicated, Resident 100 had good cognition and a BIMS score of 15. During an interview on 10/1/24 at 11:34 am, Resident 100 stated, facility staff spoke in their native language in front of Resident 100 and her roommate. During an interview on 10/3/24 at 2:52 pm, the facility's Administrator (Admin) confirmed there were ongoing issues with facility staff not speaking English in front of the residents. 2. A review of the Resident Council meeting notes, dated 7/23/24, indicated, residents of the facility voiced concerns that the staff who worked the night shift was loud at the nurse's station and during shift change. A review of the Resident Compliment or Concern document, dated 7/23/24, indicated, the DSD provided education to facility staff regarding the noise level at night and the issue was resolved on 8/7/24. During an interview on 10/1/24 at 11:34 am, Resident 100 stated the facility's staff were loud at night. A review of the undated admission Record, indicated, Resident 106 was admitted to the facility on [DATE] with the diagnosis of dysphagia following nontraumatic intracerebral hemorrhage (bleeding in the brain that caused difficulty with swallowing and was not caused by injury). Resident 106 was not her own RP (did not make own decisions). During an interview on 10/1/24 at 12:35 pm, Resident 106 stated, I feel worthless and began to cry. Resident 106 stated, I am not sleeping well and it was loud in the facility. Resident 106's family member (FM) was present and stated, it is very loud on the night shift. During an interview on 10/3/24 at 2:52 pm, Admin confirmed, there were ongoing noise concerns on the night shift. Admin stated, this morning when coming into the facility, Admin was required to tell facility staff to quiet down due to an increase in noise and reminded staff that residents were sleeping. 3. A review of the facility's policy titled Resident Rights and Dignity revised February 2021, indicated Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation 11. Staff promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of Resident 101's admission Record dated 5/28/24, indicated Resident 101 was admitted to the facility on [DATE] with diagnoses that included stroke (blood flow to the brain is blocked and some brain cells die causing disabilities), muscle weakness, difficulty in walking, and major depressive disorder. A review of Resident 101's Quarterly MDS dated [DATE], indicated Resident 101's BIMS score was 07, indicating Resident 101's cognition was severely impaired. Resident 101's Functional Abilities and Goals assessment indicated Resident 101 required maximal assistance from staff for going to the bathroom, upper and lower body dressing, putting on and taking off his footwear, and transferring from a bed to wheelchair (w/c) and back to bed. During an observation on 10/1/24 at 11:48 am, Resident 101 was observed in his room sitting in his w/c wearing only a white tee shirt and briefs (a type of underwear used for incontinence [leakage of urine and bowel]). Resident 101 was attempting to put on his long pants which were on the floor in front of him. He was leaning forward in his w/c reaching to the floor with his right hand. He had the waist band in his hand and was struggling to pull the pants on which were stuck on his feet. During an observation on 10/1/24 at 11:50 am, Resident 101 was observed in his room. CNA D entered Resident 101's room and without providing privacy and in full view of the hallway and his roommates, CNA D stood Resident 101 up, exposing his briefs and bare legs, and pulled up his pants. During an interview on 10/1/24 at 11:57 am, CNA D acknowledged he had not provided privacy when he assisted Resident 101 to get dressed and he should have, but he forgot. During an interview on 10/1/24 at 11:59 am, Resident 101 indicated he had to dress himself a lot and he felt disrespected when he would be dressed out in the middle of the room without the curtain pulled around him. During an interview on 10/3/24 at 3:06 pm, the DSD indicated it was her expectations for staff to provide privacy by drawing the privacy curtain or closing the door when they are doing personal cares.

CONCERN (E) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of records indicated Resident 40 was admitted in February 2024 with diagnoses of diabetes, epilepsy (seizure disorder), paranoid schizophrenia (a mental illness characterized by disturbances in thought), and anxiety disorder. A review of MDS, dated [DATE], indicated Resident 40 had a BIMS score of 15, indicating no cognitive (mental function) impairment. During concurrent observation and interview with Resident 40 in their room on 10/1/24 at 2:58 pm, Resident 40 stated Housekeeper A (HSK A) slams the mop on the floor and hits my bed at 7 am with the mop and wakes me up, and, I have to clean my own toilet. Resident 40 stated she had had an episode of diarrhea a while ago, and feces was on the outside of the toilet. Resident 40 stated HSK A, who spoke limited English, came to her room, pointed to the toilet, then pointed at Resident 40 and handed her paper napkins to clean the feces. During an interview with Housekeeping Manager (HSK M) on 10/3/24 at 8:43 am, HSK M stated Resident 40 informed her, [HSK A] doesn't like me and hits the bed with the mop pole when mopping. Resident 40 informed HSK M she had complained about HSK A to Certified Nurse Assistant J (CNA J) and told HSK M to Ask [CNA J]. During a phone interview with Administrator (Admin) and CNA J in Admin's office on 10/3/24 at 9:32 am, CNA J stated Resident 40 informed her months ago (did not remember the date) that HSK A wanted Resident 40 to clean the toilet using toilet paper. CNA J stated, [Resident 40] is afraid of [HSK A]. CNA J stated she spoke with HSK A and told HSK A it was her job to clean the toilet, and HSK A said she would not do that again. CNA J stated she did not report the incident to anyone. Admin acknowledged CNA J should have reported the incident to her for investigation. Admin stated she would qualify the outcome as emotional distress for Resident 40. During an interview with Admin on 10/3/24 at 12:47 pm, Admin stated she had spoken with Resident 40, who informed her the incident occurred in March 2024 (six months ago). Admin stated she called CNA J back to ask when she spoke to the housekeeper, but CNA J stated she didn't remember, It was so long ago. During an interview with Resident 40 on 10/3/24 at 2:44 pm, Resident 40 smiled, said Thank you, and stated she was so happy she had a new housekeeper clean her room today. During an interview with HSK M on 10/8/24 at 11:20 am, HSK M stated the housekeeping company will investigate the abuse allegation. HSK M stated HSK A was suspended pending investigation results, and she was awaiting Admin's paperwork. Based on interview and record review, the facility failed to ensure allegations of abuse for three out of five sampled residents (Residents 22, 35, and 40) were investigated and residents were protected during this process when: 1. Certified Nurse Assistant (CNA) M did not report suspicions of abuse when CNA M noticed Resident 22 showed fear during care. 2. CNA J did not report an allegation made by Resident 40 that the Housekeeper (HSK) A instructed Resident 40 to clean her own toilet. 3. When facility staff did not report an allegation of staff to resident physical abuse, when CNA E held down Resident 35. This placed all residents at risk for staff to resident abuse and had the potential for physical and psychosocial harm. Findings: A review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, indicated, suspicion and allegations of abuse would be investigated, and residents would be protected from further abuse during the investigation. A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation revised September 2022, the policy indicated All reports of resident abuse .are reported to local, state and federal agencies and thoroughly investigated by facility management. 1. A review of the undated admission Record, indicated, Resident 22 was admitted to the facility on [DATE] with the diagnoses of Alzheimer's Disease (memory loss), chronic pain, and depression. Resident 22 was not her own responsible party (RP, decision maker). A review of Resident 22's Annual Minimum Data Set (MDS, an assessment tool), dated 8/27/24, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) had been performed. Resident 22 had a BIMS of 8, which indicated Resident 22's memory was moderately impaired. A review of Resident 100's undated Admissions Record, indicated, admission to the facility on 5/11/24 with the diagnoses of heart failure and depression. Resident 100 was her own RP. A review of Resident 100's Quarterly MDS, dated [DATE], indicated, Resident 100 had good cognition and a BIMS score of 15. During an interview on 10/1/24 at 11:34 am, Resident 22 stated, the CNAs that worked the night shift handled Resident 22 roughly when providing personal care (repositioning, providing incontinence care). Resident 100 (Resident 22's roommate) stated, witnessing CNAs handle Resident 22 in a rough manner while providing care. During an interview on 10/3/24 at 11:12 am, CNA M stated, Resident 22 had not voiced concerns regarding CNAs being rough during care. CNA M stated, Resident 22 appeared afraid while CNA M had provided personal care in the past and this was a new behavior. CNA M stated, Resident 22 had chronic pain and there was a difference between being afraid of care and having pain during care. CNA M confirmed, having suspicions of potential abuse due to Resident 22's change in behaviors (becoming fearful) and did not report it to anyone. During an interview on 10/3/24 at 2:42 pm, the facility's Administrator (Admin) confirmed, when staff suspected abuse, it should be reported and investigated, and it was not. 3. A review of Resident 35's admission Record dated 8/27/24, indicated he was re-admitted on [DATE] with the diagnoses that included lung disease, depression, left sided paralysis (unable to move his left arm and leg), adult failure to thrive (the feeling of wanting to give up on life), colostomy (a surgical procedure that redirects the colon to an opening in the abdominal wall in which the bowel will exit into a bag), and an indwelling urethral catheter (a tube that goes into the bladder and drains the urine into a collection bag). A review of Resident 35's admission Minimum Data Sheet (MDS, a standardized assessment of an adult's functional, medical, psychosocial, and cognitive status) dated 9/19/24, indicated Resident 35's Brief Interview for Mental Status (BIMS, evaluates a person's cognition, [ability to think, learn, remember, use judgement, and make decisions] with scores from 00 to 15) score was 15 indicating his cognition was intact and he could make his own decisions. Resident 35's level of functioning assessment indicated Resident 35 required full help from staff with toileting hygiene (the ability to clean the bottom after going to the bathroom, adjust clothes before and after urinating or having a bowel movement. If managing an ostomy, include wiping the opening.), upper and lower body dressing, and mobility (moving from his back to his left side or his right). During an observation and interview on 10/1/24 at 2:57 pm, Resident 35 was observed lying in bed with many items (iPad, papers, and other items) on his over bed table and on his bed. Resident 35 stated He (CNA E) grabbed me, he held me down because I took a swing at him. He was messing with my stuff. He was touching my iPad to move it. He would not listen to how I told him to do it. He (CNA E) still comes in my room and leaves the lights on. He is doing it on purpose. I told my nurse about it Resident 35 indicted he was distressed and upset and did not want CNA E to come in his room and was told by a nurse that CNA E would not be coming in this room anymore, but he still was. During an interview on 10/2/24 at 3:40 pm, CNA H indicated that Resident 35 had told him about a staff member that had held him down and was messing with his iPad. During an interview on 10/2/24 at 3:53 pm, the Assistant Director of Nursing (ADON) indicated there had been no report or investigation of a CNA holding down Resident 35 During an interview with the Administrator (Admin) on 10/2/24 at 3:56 pm, the Admin indicated she had not heard of any CNA holding down Resident 35. During an interview with CNA E and Admin on 10/2/24 at 4:04 pm, CNA E confirmed that he had grabbed Resident's arm while trying to perform cares and he should not have. He indicated that he told the Infection Preventionist (IP) and a charge nurse. The Admin confirmed there was no investigation or report to the local state or federal agencies and there should have been. During an interview with the IP on 10/2/24 at 4:20 pm, the IP confirmed that CNA E told her that Resident 35 was being aggressive, and she informed him to tell his charge nurse. She indicated she had not followed up on this. During an interview with the Director of Staff Development (DSD) on 10/2/24 at 4:25 pm, the DSD confirmed that CNA E had told her about the incident with Resident 35. DSD indicated the incident happened on 9/15/24 during the night shift. DSD indicated she informed the Staffing Coordinator (SC) to change CNA E's assignment. DSD confirmed that there should have been an investigation into this event but there had not been. During a review of the facility's assignment sheets dated 9/15/24 thru 10/1/24, CNA E was assigned to care for Resident 35 on 9/15/24, 9/24/24, 9/25/24, 9/26/24, 9/27/24, 9/30/24, 10/1/24. During an interview on 10/2/24 at 4:33 pm, SC confirmed CNA E was assigned to care for Resident 35 after the incident and he should not have been.

CONCERN (E)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to provide medically related Social Services, that met the needs of the residents, for four out of 22 sampled residents (Residents 35, 87, 90, and 98) when: 1. Social Service care plans (a document that described resident goals and the interventions [instruction, actions, education, and care required] that facility staff would utilize to assist in residents reaching their goals) were not updated quarterly (every 3 months) or as needed for Residents 87 and 90. 2. Care conference meeting (meeting held quarterly to discuss care, needs, and goals, that included the resident, social services, nursing, activities director and the dietary department) notes did not reflect a discharge plan or discharge planning needs for Resident 90. 3. Social Services did not assist Resident 90 with financial documents when requested. 4. Outside services and referrals were not made in a timely manner for Resident 98. 5. Dental services were not provided in a timely manner for Resident 35. These failures had the potential for needs to go unmet and cause a delay in needed care which could lead to a decline in health and psychosocial wellbeing. Findings: During a review of the facility's policy, titled, Social Services, revised 10/2010, indicated the facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The services statement indicates: - The Director of Social Services is a qualified social worker and is responsible for: a. Consultation with other departments regarding program planning, policy development, and priority setting of social services. b. An adequate record system for obtaining, recording, and filing of social service data - Medially-related social services is provided to maintain or improve each resident's ability to control everyday physical needs (e.g., appropriate adaptive equipment for eating, ambulation, etc.); and mental and psychosocial needs (e.g., sense of identity, coping abilities, and sense of meaningfulness or purpose). - Factors that have a potentially negative effect on psychosocial functioning include: a. Institutional attitudes and practices which affect the resident's dignity and sense of control. b. Disability or loss of function. c. Presence of a progressive, chronic disabling condition (i.e., Multiple Sclerosis, Chronic Obstructive Pulmonary Disease, Alzheimer's disease, mental illness). d. Behavioral problems (i.e., confusion, anxiety, loneliness, depressed mood, anger, fear, wandering, psychotic episode) - The social services department is responsible for: a. Identifying individual social and emotional needs. b. Assisting in providing corrective action for the resident's needs by developing and maintaining individualized social services care plans. c. Maintaining regular progress and follow-up notes indicating the resident's response to the plan and adjustment to the institutional setting. d. Compiling and maintain up-to-date information about community health and services agencies available for resident referrals. e. Making referrals to social services agencies as necessary or appropriate. f. Maintain appropriate documentation of referrals and providing social service data summaries to such agencies. g. Making supportive visits to residents and performing needed services (i.e., communication with the family or friends, coordinating resources and services to meet the resident's needs). h. Informing the resident or representative (sponsor) of the resident's personal and property rights as well as serving on the group council to assure that complaints and grievances are promptly answered/resolved. i. Working with individuals and groups in developing supportive services for residents according to their individual needs and interests. j. Participating in interdisciplinary staff conferences, providing social service information to ensure treatment of the social and emotional needs of the resident as a part of the total plan of care. k. Participating in the planning of the resident's admission, return to home and community, or transfer to another facility by assessing the impact of these changes and making arrangements for social and emotional support . - Inquiries concerning social services should be referred to the Director of Social Services. During a review of the facility's job description, titled, Social Worker, revised 10/20, signed by the Social Service Director (SSD), dated 1/23/22, indicated the primary purpose of this position is to assist in implementing, evaluating and participating in the overall operation of the social services department in accordance with current federal, state, and local standards and regulations. The duties and responsibilities include: - Implement the social services programs of the facility under the direction of the Administrator and the Director of Social Services. - Participate in the facility assessment and assess individual social services needs and resources. - Assist in obtaining resources from community social, health and welfare agencies to meet the needs of the resident. - Coordinate social services activities with other members of the interdisciplinary team (IDT). - Assist residents, representatives and families with seeking financial assistance, discharge planning (including collaboration with community agencies) and referrals to other community agencies. - Meet with administration, medical, and nursing staff as well as other related departments in planning social services programs and activities. - Participate in the development of a resident-centered care plan for each resident. - Involve the resident/family in planning individualized objectives and goals for the resident. - Communicate the social, psychological and emotional needs of the resident/family to other members of the IDT. - Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. - Coordinate transfer or discharges for residents. - Manage the transfers or discharges process when a resident has appealed. - [NAME] residents who are being transferred to another facility or who are being discharged ; assist residents and their resident representatives in selecting a post-discharge care provider. - Refer residents/families to appropriate social services agencies when the facility does not provide the services or needs of the residents. 1. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 3/1/22, indicated, the care plan would be updated quarterly. A review if the facility's P&P titles, Social Services, dated 10/1/10, indicated, social services would assist .in providing corrective action for the resident's needs by developing and maintaining individualized social services care plans. A review of the undated admission Record, indicated, Resident 87 was admitted to the facility on [DATE] with the diagnoses of malignant neoplasm of tonsil (a type of head and neck cancer), gastrostomy status (g-tube), and dysphagia, oropharyngeal phase (swallowing problems). Resident 87 was his own responsible party (RP, decision maker). A review of Resident 87's Quarterly Minimum Data Set (MDS, an assessment tool), dated 7/8/24, indicated, a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) had been performed. Resident 87 had a BIMS of 15, which indicated Resident 87's memory was intact. A review of Resident 87's Care Conference, dated 4/5/24, indicated, Resident 87's discharge plan included being transferred to a facility in Sacramento because he is familiar with the area and he'd be closer to his mom, who is on hospice. During a concurrent interview and record review on 10/4/24 at 9:33 am, with SSD, Resident 87's discharge care plan, dated 4/9/24, was reviewed. SSD stated, Resident 87 was admitted to the facility for short term care and wanted to transfer to a facility in the Sacramento area to be closer to his mom. SSD stated care plans were updated quarterly and as needed. SSD confirmed, Resident 87's care plan indicated Resident 87 was admitted for long term care (not short-term care), was not updated quarterly or as needed, and did not reflect Resident 87's desire to transfer back to the Sacramento area and should have. A review of the undated Admissions Record, indicated Resident 90 was admitted to the facility on [DATE] with the diagnoses of type 2 diabetes and high blood pressure. Resident 90 was his own RP. A review of Resident 90's Quarterly MDS, dated [DATE], indicated, Resident 90 had a BIMS of 15 and Resident 90's memory was intact. A review of Resident 90's Care Conference, dated 1/28/24, indicated Resident 90's discharge plan was uncertain. A review of Resident 90's discharge care plan, dated 2/1/24, indicated Resident 90 was admitted to the facility for a short-term stay. There was no care plan update noted. During a concurrent interview and record review on 10/3/24 at 2:52 pm, the facility's Administrator (ADMIN) stated, discharge planning started upon admission to the facility and that care plans were updated quarterly. ADMIN reviewed Residents 87 and 90's care plan. ADMIN confirmed, SSD had not updated the care plans quarterly to reflect the discharge plan and should have. 2. A review of the Social Worker job description, dated 1/23/22, indicated, the Social Services Director (SSD) would Assist residents, representatives and families with seeking financial assistance, discharge planning .and referrals to other community agencies. A review if the facility's P&P titles, Social Services, dated 10/1/10, indicated, social services participated in the planning of assisting residents during the discharge process and maintained social services documentation. During an interview on 10/2/24 at 10:03 am, Resident 90 stated, that Resident 90 needed assistance with finding housing and a care giver so that Resident 90 could be discharged from the facility. Resident 90 stated, the SSD would not assist with a discharge plan. During a concurrent interview and record review on 10/3/24 at 12:56 pm, SSD stated, discharge planning started once the resident was admitted to the facility. SSD reviewed Resident 90's Care Conference meeting note, dated 1/28/24, and stated the meeting note indicated, Resident 90's discharge plan was uncertain. SSD stated, there was no discharge plan because Resident 90 had nowhere to go. SSD stated, maybe there was a breakdown in communication and was unaware that Resident 90 wanted to discharge because Resident 90 had not vocalized wanted to be discharged . During a concurrent interview and record review on 10/3/24 at 2:52 pm, with ADMIN, Resident 90's Care Conference meeting notes, dated 4/3/24 and 7/29/24 were reviewed. ADMIN confirmed, the meeting notes did not include information from SSD regarding a discharge plan and should have. 3. A review if the facility's P&P titles, Social Services, dated 10/1/10, indicated, social services assisted residents with financial needs or problems. During an interview on 10/2/24 at 10:03 am, Resident 90 stated, that Resident 90 needed assistance with obtaining an income so that Resident 90 could be discharged . Resident 90 stated, asking SSD for assistance with disability paperwork and the SSD told Resident 90 there were things the SSD did not do. During an interview on 10/3/24 at 12:56 pm, SSD stated, Resident 90 did not have a discharge plan and did not have any money. SSD stated, SSD did not know disability paperwork and SSD spoke with Adult Protective Services to assist Resident 90 with applying for disability. During an interview on 10/3/24 at 2:52 pm, ADMIN stated, SSD was expected to assist residents with finances and SSD should have assisted Resident 90 with disability paperwork. 5. A review of the Social Service job description dated 1/23/22 and signed by the SSD on 1/23/22, the job description indicated the duties and responsibilities of the SSD are to assist in obtaining resources from community, social, health and welfare agencies to meet the needs of the resident. A review of the facility policy titled Dental Examination/Assessment revised December 2013, indicated Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. A review of Resident 35's admission Record dated 8/27/24, indicated he was re-admitted on [DATE] with the diagnoses that included lung disease, depression, left sided paralysis (unable to move his left arm and leg), adult failure to thrive (the feeling of wanting to give up on life), colostomy (a surgical procedure that redirects the colon to an opening in the abdominal wall in which the bowel will exit into a bag), and an indwelling urethral catheter (a tube that goes into the bladder and drains the urine into a collection bag). During a concurrent observation and interview of Resident 35 on 10/1/24 at 3:02 pm, Resident 35 was observed in his room lying in bed. Resident had no teeth in his mouth. Resident 35 stated They (a dentist that came to the facility) pulled them out and now they say they cannot give them (dentures) to me because I do not have insurance. I was eating good with the teeth I had in my mouth, now I cannot chew the bread it is too hard. During an interview on 10/03/24 at 11:36 am, the SSD indicated Resident 35 had his teeth extracted on December 8, 2023, by a facility contracted dental service, and impressions and x-rays were done on January 12, 2024. During an interview on 10/3/24 at 11:37 am, the Social Service Assistant (SSA) indicated Resident 35's insurance plan had changed, and the contracted dental services will not honor the new insurance. A review of Resident 35's dental notes from (Dental Name) Healthcare dated 12/08/23, showed Resident 35 had 4 teeth extracted. A review of Resident 35's dental notes from (Dental Name) Healthcare dated 1/12/24, showed Resident 35 had upper and lower impressions taken for new dentures. A review of Resident 35's Care Conference dated 6/2/24, showed notes written by the SSD Daughter also asks that we follow up with his dentures. A review of an e-mail by Patient Care Coordinator (PCC) from (Dental Name) Healthcare dated 6/13/24, indicated I have called a couple of times to discuss a couple of patients that their denture process is on hold due to their (Insurance name). During an interview on 10/3/24 at 1:56 pm, the SSD indicated she had not called the contracted dental services to follow up on Resident 35 dentures until his daughter brought it up at the care conference 5 months after he had his teeth pulled and impressions done. The SSD indicated that she should have followed up on it. 4. During a review of Resident 98's clinical record, indicated that Resident 98 was admitted on [DATE] with diagnoses which included end stage renal disease (ESRD, also known as kidney failure, is a terminal illness that occurs when the kidneys can no longer function properly), benign neoplasm (benign tumor) on right eyelid, and dependence on renal dialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally.) He was his own healthcare decision maker. During a review of Resident 98's MDS, dated [DATE], indicated Resident 98's cognition was intact. During a review of Resident 98's clinical record, titled, Social Service Bundle assessments, dated 8/2/24, and 9/21/24, at the section Discharge Planning, indicated that Resident 98, right eye covered with eye patch. Resident 98 says There a bug in there and I need a procedure to fix it. During a review of Resident 98's care plan, initiated on 8/2/24 by SSD, indicated, Resident 98 has a visual deficit and requires the use of prescription glasses. His right eye is also covered due to [Other benign Neoplasm of skin of eyelid. Including canthus (the outer or inner corner of the eye, where the upper and lower lids meet.). The interventions were to, Monitor eyes for redness, discharge, irritation, itchiness, burning, pain and swelling, and Ophthalmology or Optometry consult as needed. Or upon request. During a concurrent observation and interview on 10/1/24 at 9:37 am with Resident 98, observed Resident 98's right eye was covered with a large bandage. Resident 98 stated, I had a wart and it's growing into my eye . Resident 98 stated that he had been worried and asking about getting his surgery done ever since he was admitted to the facility, and he was worried about losing his right eye. Resident 98 stated, No one is helping me get the surgery I need. I don't want to lose my eye. I don't want to lose my vision . Resident 98 stated he couldn't sleep at night because he was worried, and he had complained multiple times, no one was helping him. Resident 98 stated he wanted to be discharged so he could take care of his eye because no one in the facility would help him. During an interview on 10/1/24 at 11:26 am with Resident 98, Resident 98 stated, I had to go out and get myself an eye doctor. I had pre-op, lab work and surgery appointments in September, the facility missed them all During a review of Resident 98's social service progress notes from 8/2/24 to 10/1/24, there's no note indicated that Resident 98 had been referral to see an ophthalmology or had been set up with the transportation to follow up with any exiting eye appointment. During an interview on 10/3/24 at 11:11 am with the Director of Nursing (DON), Resident 98's social service assessment was reviewed. The DON stated she was not made aware of Resident 98's pre exiting eye appointment until 9/30/24 when SSD informed her about Resident 98's appointment, she started making phone call. The DON stated, When someone had an appointment, we would arrange the appointment and transportation for Resident 98. We would honor it, and the Interdisciplinary team (IDT - a gathering of healthcare providers from different disciplines to coordinate care for a patient) meeting would be discussing it. During a concurrent interview and record review on 10/4/24 at 3:30 pm with the SSD, Resident 98's care plan, initiated on 8/2/24, and Social Service Assessments, dated 8/2/24, and 9/21/24, were reviewed. The SSD admitted that she initiated the care plan for Resident 98's eye, and she did not send Ophthalmology referral. The SSD also stated that she did the assessments on 8/2/24 and 9/21/24, and was aware of Resident 98's eye appointment, the SSD stated, I told the DON, it's the nursing's job to follow it up, not mine. However, the SSD was not able to provide any record indicating that she had notified the nursing staff/DON about Resident 98's eye appointments.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure medications and medication supplies were stored and labeled in accordance with currently accepted professional principles when: 1. Two loose pills were found in the drawer of medication cart 2. 2. Six medications that were being dispensed were opened and not dated. 3. Four Foley drainage bags (A bag that collects urine which comes from the bladder through a catheter tube) in a storage room ready for use were expired. 4. Pro-Stat concentrated liquid protein medical food was being dispensed but had expired. These failures had the potential for medication misuse, medication ineffectiveness, and potential exposure to harmful pathogens (bacteria, viruses, fungi) from expired supplies for residents. Findings: 1. During a concurrent observation and interview with the Assistant Director of Nursing (ADON) on 10/2/24 at 10:12 am, an inspection of medication cart 2 was performed. Two loose pills were observed in the middle drawer the medication cart. The ADON confirmed that there should not be loose pills in the cart. 2. During a concurrent observation and interview with Director of Nursing (DON) in the Medication Storage room on 10/01/24 at 11:03 am, two bottles of Tuberculin (a medication uses to test for tuberculosis), and one tube of Muscle Rub Cream were noted to have been opened but were not marked with the date they were opened. DON confirmed it was the policy of the facility that all medications should be dated with the date opened and discarded within 30 days of opening. During a concurrent observation and interview with the ADON on 10/2/24 at 10:12 am, an inspection of medication cart 2 was performed. Two bottles of Enulose (a liquid medication used for liver disease) and a bottle of Geri tussin DM (a liquid medication used for symptoms of cough), that were being dispensed to residents, were noted to have been opened but were not marked with the date they were opened. The ADON confirmed it was the policy of the facility that all medications should be dated with the date opened. 3. During a concurrent observation and interview with DON in the Medication Storage room on 10/01/24 at 11:03 am, four Foley drainage bags were past the expiration date of 3/26/24. The DON confirmed it was the policy of the facility that expired medications or supplies should be discarded and not available for use. 4. During a concurrent observation and interview with the ADON on 10/2/24 at 10:12 am, an inspection of medication cart 2 was performed. Pro-Stat concentrated liquid protein medical food (a liquid protein used for the dietary management of wounds and other conditions requiring increased protein) was dated opened on 6/30/24 and the storage instructions on the bottle were to discard three months after opening. The ADON confirmed that this protein drink was expired and should have been discarded on 9/30/24. A review of the facility's policy titled Medication Administration General Guidelines (undated), the policy indicated No expired medication will be administered to a resident. The nurse shall place a date opened sticker on the medication if one is not provided by the dispensing pharmacy and enter the date opened.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During initial kitchen tour on 10/1/24 at 9:03 pm, observed an unused plate warmer present in the dry storage room. Observed a piece of paper titled Meal Times posted on the wall indicating breakfast was served at 7 am, lunch at 12 pm, and dinner at 5 pm. During an interview with Dietary Manager (DM) on 10/2/24 at 5:53 am, DM stated the plate warmer in the dry storage room was new and had not been used yet but had metal bases that would keep food warmer for longer. DM stated she requested the purchase because the old warmer didn't keep food hot enough. DM stated resident complaints used to be palatability and taste, but that went away when COOK 2 was hired in August. DM stated, It's just temperature now, complaints about food not warm enough. DM stated that would be fixed with the new plate warmer. During observation of tray-line food preparation on 10/3/24 at 11:35 am, observed COOK 1 remove multiple pizzas from the oven. Pizzas were placed on surfaces without a heat source. Observed COOK 1 attempting to slice one pizza with difficulty; observed the pizza crust to be dark brown on the bottom. The pizza was sliced and placed on plates by COOK 1 for distribution to residents. Food carts were loaded with resident trays. Cart 1 left the kitchen at 12:21 pm, Cart 2 at 12:35 pm, Cart 3 at 12:53 pm, and Cart 4 at 1:20 pm. During concurrent kitchen observation and interview with DM on 10/3/24 at 1:25 pm, observed a chart posted which indicated which room numbers received food deliveries from Carts 1 through 4. DM stated carts go out in order, 1 through 4. DM stated they stick to that [schedule] unless there's COVID. When asked if 90 minutes from first tray to last tray was normal, DM stated they were doing great if tray line started at noon and last trays were delivered before 1:30 pm. During concurrent test tray observation/tasting and interview with Certified Dietary Manager (CDM) on 10/3/24 at 1:30 pm, pizza slice temperature taken with CDM's food thermometer indicated 95 degrees. CDM stated, Ideally, the temperature should be over 135 degrees for proper service of hot food. After tasting the pizza, CDM acknowledged the temperature was lukewarm. CDM acknowledged seeing the pizza with a dark brown crust and stated it should not have been served to residents. CDM stated a solution to cold food complaints could be to cook pizza in stages so it could be served hot and to rotate tray cart delivery times to prevent the same residents from getting the last food trays. During an interview with Social Services Assistant (SSA) on 10/4/24 at 11:41 am, SSA stated the DM listens to criticisms about food, responds well, and will talk to residents about concerns. SSA stated DM is overwhelmed with hearing about all the complaints. A review of policy and procedure (P&P) titled Food: Preparation, dated 9/2017, indicated the Dining Services Director/Cook(s) were responsible for food preparation techniques which minimize the time food items are exposed to temperatures greater than 41 degrees and/or less than 135 degrees, or per state regulation. All foods will be held at appropriate temperatures, greater than 135 degrees (or as state regulation requires) for hot holding and less than 41 degrees for cold food holding. A review of P&P titled Meal Distribution: Infection Control Considerations, dated 9/2017, indicated (1) all meals will be assembled in accordance with individualized diet orders, plan of care, and preferences, and . (3) all food items will be transported promptly for appropriate temperature maintenance. 3. A review of Resident 11's admission Record dated 2/2/24, indicated she was admitted on [DATE] with the diagnoses that included lung disease, dysphagia (difficulty swallowing), depression, and right sided paralysis (not able to move right arm or leg). A review of Resident 11's Quarterly MDS, dated [DATE], indicated Resident 11's Brief Interview for Mental Status (BIMS, evaluates a person's cognition, [ability to think, learn, remember, use judgement, and make decisions] with scores from 00 to 15) score was 15 indicating her cognition was intact and she could make her own decisions. During an interview on 10/1/24 at 12:27 pm, Resident 11 indicated that her ice cream comes melted. She indicated they should take the ice cream around after we get our trays which was around 1:30 pm. During observation of tray line on 10/3/24 at 1:25 pm, ice cream on resident trays in the last food cart appeared soft. On squeezing a plastic ice cream cup, both sides were easily pushed in, indicating the ice cream was not frozen. 4. A review of Resident 35's admission Record dated 8/27/24, indicated he was admitted on [DATE] with the diagnoses that included lung disease, depression, left sided paralysis, and adult failure to thrive (the feeling of wanting to give up on life). A review of Resident 35's Yearly MDS dated [DATE], indicated Resident 35's BIMS score was 15 indicating his cognition was intact and he could make his own decisions. During an interview on 10/1/24 at 3:01 pm, Resident 35 indicated that his food was always cold, his ice cream comes melted and his biscuits were burnt this morning. He stated the smell is making me sick. Resident 35 indicated he had told the CNA's these concerns. During an interview with the Dietary Manager (DM) on 10/3/24 at 3:26 pm, the DM indicated they had just got a new plate warmer today (10/3/24) because the previous plate warmer did not keep the plates hot enough to keep the food warm. The DM said there had been complaints about the food being cold. During an interview on 10/1/24 at 3:44 pm, CNA K indicated the food carts come out late and the residents have told me that the food is cold, so I warm it up for them. 5. A review of Resident 215's admission Record dated 9/9/24, indicated she was admitted on [DATE] with the diagnoses that included lung disease, muscle weakness, and depression. She was her own responsible party (RP, she made her own decisions concerning her care). A review of Resident 215's admission MDS dated [DATE], indicated Resident BIMS score was 15 indicating her cognition was intact. During an observation and interview on 10/3/24 at 1:44 pm, Resident 215 was observed eating her lunch in her room. Resident 215 held up the pizza she was eating that had come on her tray. The bottom of the pizza was black and hard. Resident indicated that the pizza was burnt, and she did not like it that way but suffered through eating it that way anyway. CNA F confirmed the pizza was burnt and should not have been served that way. Based on observation, interview and record review, the facility failed to prepare and serve food that maintained an appetizing flavor, texture, appearance, and at a palatable (pleasant taste) temperature when 5 of 22 sampled residents (Residents 11, 35, 77, 84, 215) when: 1.Resident 77 stated the food was overcooked and could not even cut it. 2. Resident 84 stated the pork was undercooked, and he had to throw it away. 3. Resident 11's ice cream was served melted. 4. Resident 35's food was served cold, ice cream was served melted, and biscuits were served burnt. 5. Resident 215's pizza was served burnt. These failures resulted in meals to be served overcooked, undercooked, cold, unpleasant, and not meet the resident food preference, which had the potential for residents to decrease meal intakes and have weight loss issues. Findings 1. During a review of Resident 84's clinical record, indicated that Resident 77 was admitted to the facility on [DATE] with diagnoses which included stroke, diabetes (high blood sugar), and hypertension. He was his own healthcare decision maker. During a review of Resident 84's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 7/25/24, indicated Resident 77's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. During an interview on 10/1/24 at 10:20 am with Resident 77, Resident 77 stated that he was the President of the Resident Council (a group of residents in a long-term care facility who meet regularly to discuss concerns, plan activities, and advocate for change), and the problem with the food had been brought up several times, and it had not been solved. Resident 77 stated, For weeks, the sausage was burnt. I couldn't even cut it. The Certified Nursing Assistant (CNA) went down to the kitchen to get a new sausage for me, and it's still burnt. This morning, the gravy was cold. They kept telling me the plate warmer is coming, but it has been 5 months I talked to the Dietary Manager (DM) every month, and nothing got done. 2. During a review of Resident 84's clinical record, indicated that Resident 84 was admitted to the facility on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and hypertension. He was his own healthcare decision maker. During a review of Resident 84's MDS, dated [DATE], indicated Resident 84's cognition was moderately impaired. During an interview on 10/1/24 at 12:21 pm with Resident 84, Resident 84 stated, I don't like this cut up pork. It's almost raw, every time I ate it, I s**t, I just threw it away!

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety when: 1. Food was not properly stored, labeled and dated, with expired food items present in kitchen refrigerator/freezers. 2. Kitchen and food service equipment was not in sanitary condition; 3. The kitchen environment was not in sanitary condition; 4. Resident food was not stored or labeled per policy and procedure (P&P) in the resident refrigerator/freezer, and the refrigerator was visibly dirty inside. These failures created the potential risk for exposure to food- and waterborne illnesses in a medically vulnerable population of 105 residents who receive food stored and prepared in the facility. Findings: 1. A review of P&P titled Refrigerators and Freezers, dated 12/2014, indicated the facility will: A. Ensure safe refrigerator/freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. B. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. C. Use by dates will be completed with expiration dates on all prepared food in refrigerators. D. Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary. A review of the 2022 Food Code, United States (US) Food and Drug Administration (FDA), 3-501.17, Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking indicated: Except when packaging food using reduced-oxygen packaging methods (vacuum-sealed), refrigerated, ready-to-eat foods prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F - a unit of measure) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. During observation on initial kitchen tour on 10/1/24 at 9:03 am, observed: A. An open jar of applesauce in Refrigerator 2 labeled use by date of 9/29/24. B. A foil-covered metal container in Refrigerator 1 labeled Puree bread made 9/28/24 with no use by date. C. A Ziplock bag contained seven boiled eggs in Refrigerator 2 with no label/dates. D. An open container of curry powder indicated use by date of 8/21/24. E. The label for an open container of ground rosemary was peeled off; no opened/use by dates were seen. F. Two open, unsealed, undated bags of sliced bread in dry storage area. G. A bag of unused cocoa powder with a small hole in the seam, with cocoa powder spilling onto food storage shelving. H. The top rack of the walk-in refrigerator contained an undated prepackaged meat and cheese sandwich together with a grocery store plastic bag with undated food items. I. An egg in Refrigerator 2 with dried, yellow, yolk-like substance on the shell. During a concurrent observational kitchen tour and interview with Registered Dietitian (RD) on 10/1/24 at 9:53 am, RD acknowledged the hole in the cocoa powder bag had been there for an unknown length of time and may allow bacteria or pests to enter the bag. RD acknowledged food items should be discarded if packaging was compromised. RD stated the open bread bag should have been closed and labeled with an opened on date. During concurrent observational kitchen tour and interview with COOK 2 on 10/1/24 at 9:29 am, COOK 2 stated facility policy for foods stored in refrigerators and freezers is first in, first out, indicating foods received or opened first should be used before using/opening other items. COOK 2 stated staff are supposed to write an opened on date on food items but she sometimes forgets. During a concurrent observation of the kitchen and interview with Dietary Manager (DM) on 10/2/24 at 5:53 am, DM stated the expired applesauce in Refrigerator 2 was not labeled correctly. DM stated it should have been dated to expire 10/1/24, four days after the opened date of 9/27/24. DM acknowledged the egg with yellow substance on its shell was an infection control issue and should have been discarded, and the bag of boiled eggs should have been dated. DM stated the prepackaged sandwich was a staff members lunch and acknowledged staff food should not be stored with resident food. Observed an open bag of bread crusts, undated, on dry storage shelves. DM acknowledged the bag should have been tied closed and dated. During an interview with COOK 2 on 10/3/24 at 11:35 am, when discussing cooling and reheating measures for cooked/prepared foods, COOK 2 stated, We cook to serve. We don't do leftovers. 2. A review of P&P Meal Distribution: Infection Control Considerations, dated 9/2017, the P&P indicated meal service and ware washing (washing of dishware and utensils) for residents with infectious conditions will follow the guidelines of the Federal Center for Disease Control (CDC) or as directed by the local or state health officials. A review of the 2022 Food Code, US FDA, 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated: 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 accumulations. C. Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. A review of Job Description, Cook (undated) indicated the cook prepares food in accordance with current applicable federal, state, and local standards, guidelines, and regulations, in line with established facility P&Ps, to ensure quality dining services are provided at all times. The cook assists in assuring proper receiving, storage, preparation, serving, sanitation, and cleaning procedures are followed. The cook must assist dietary aides (DAs) as necessary and supervises DAs in the preparation and serving of foods and beverages. The cook follows posted cleaning schedules utilizing proper sanitation and cleaning methods, cleans food preparation and utensils after use and meal service, and is responsible for washing dishes and cleaning the kitchen to keep it sanitary and up to health standards. A review of Job Description, Dietary Aide (DA) (undated) indicated DAs assist the cook in preparation and service of meals. DAs prepare and deliver food and trays, wash dishes, and clean and sanitize the kitchen according to health standards, ensuring cleaning schedules are followed using proper sanitation and cleaning methods. DAs clean food preparation areas and utensils after use and meal service and are responsible for washing dishes and cleaning the kitchen to keep it sanitary and up to health standards. A review of Concern/Grievance Log indicated a resident complaint on 7/8/24 for food portions and cleanliness of drinkware. Staff assigned to follow up the complaint were the Administrator, DM, and Director of Nursing. The plan of action was to do in-service for staff. A review of Inservice/Meeting Sign in Sheet, dated 9/10/24, indicated an in-service was held by instructors CDM and DM and covered job descriptions, professionalism, cleanliness, and tray cards. COOK 1, COOK 2, DA I, DA J, and DA K were among those in attendance. During initial observational kitchen tour on 10/1/24 at 9:03 am, observed: A. Thick, black, crusty debris and food particles under stovetop burners. B. A brown, greasy-appearing substance splattered on the stove backsplash. C. Drips of dried brown and tan substances down the fronts and sides of ovens and clumps of white flour-like powder spilled on the bottom shelf of the microwave stand and on the side of oven next to it. D. Dust and food crumbs on the shelf over the stovetop. E. Metal food delivery cart with visible food crumbs on tray holders and spills soiling the front frame. F. Food crumbs and a dried yellow substance near a box of eggs in Refrigerator 2. G. A dried white substance splashed on sides and top of the food mixer and sides of the refrigerator next to it. H. Brown-grey residue on the can opener blade. I. Food crumbs on top of the knife holder with visibly soiled knife handles protruding from the holder. J. A cold plate of bacon, hashbrowns, two biscuits, and gravy in the microwave. During concurrent observation and interview with COOK 2 on 10/1/24 at 9:03 am, COOK 2 tested the sanitizer solution in the three-compartment dishwashing sink. COOK 2 stated the solution consisted of water and quaternary ammonium (a sanitizing agent that kills bacteria). The test strip revealed a quaternary strength of 500 parts per million (ppm - a unit of measure). Observed a poster titled Ecolab: Oasis 146 Multi-Quat Sanitizer, dated 2015, on the wall over the three-compartment dishwashing sink which indicated the acceptable range for quaternary solution was between 150 and 400 ppm. During concurrent observation and interview with DA J and DA I at dishwashing station on 10/1/24 at 9:29 am, DA J stated the dishwasher used low heat and chlorine to sanitize dishes. DA J stated dishwasher temperature should be between 120 to 150 degrees. Observed DA J test dishwater for chlorine level; test strip indicated chlorine level was 50 parts per million (ppm - a unit of measure). DA I stated she did not know what the chlorine level should be. Observation of Dish Machine Log, dated September 2024, indicated wash temperatures should be between 120 and 140 degrees and Manufacturer Recommended PPM was 75 ppm. The log indicated columns for temperatures and chlorine levels to be documented at breakfast, lunch, and dinner times. Entries were not logged for dinner 9/21/24 and lunch 9/23, 9/27, and 9/28/24. During a concurrent observation of the kitchen and interview with Dietary Manager (DM) on 10/2/24 at 5:53 am, DM stated discussed missing dish station log entries on 10/1/24 with CDM. DM stated one shift was a disaster and she was frustrated. DM stated she had just educated staff on log entries, but certain staff needed frequent re-education. DM acknowledged stovetop and ovens were not clean and were an infection control issue. Observed residue on the can opener blade. DM acknowledged it was not clean and sent it through the dishwasher. A knife removed from the knife holder revealed a dried piece of lettuce stuck to the blade. Food crumbs were present on top of the knife holder. DM acknowledged the soiled knives and knife holder to be an infection risk, noting the wall-mounted knife holder would need to be removed by maintenance for sanitizing due to the potential for knives to be repeatedly exposed to bacteria. Observation of the steamer indicated a moist brown residue along the door seal. DM wiped a white sanitizing cloth across the area; brown residue was observed on the cloth. DM acknowledged the steamer was not clean and was an infection control issue. Asked about the dishwasher, DM stated Ecolab presets the sanitizer levels to be delivered to the dishwasher and three-compartment sink. Informed DM that the third sink quaternary level was 500 ppm on 10/1/24, DM stated, That's too much. DM stated the contracted supplier sets. During concurrent kitchen observation and interview with Certified Dietary Manager (CDM) on 10/3/24 at 11 am, CDM tested a red bucket containing sanitizing solution of water and quaternary ammonium to reveal quaternary strength of 150 ppm. CDM stated the sanitizer solution was used to sanitize kitchen surfaces and equipment and should be between 200 and 400 ppm to be effective. CDM acknowledged 150 ppm would not be sufficient to sanitize as it may not kill all bacteria. Discussed that quaternary test strip showed 500 ppm at three-compartment sink on 10/1/24, and CDM stated a quaternary strength over 400 ppm was a waste of product . It goes inert after a time. During concurrent observation of tray line and interview with Dietary Aide I (DA I) on 10/3/24 at 11:05 am, observed a shallow plastic container of juice cups covered with plastic lids. Ice cubes were observed on several lids and on the bottom of the container. DA I stated she placed ice over the drink lids to keep it cold, then placed the cart in the refrigerator until ready to serve. During concurrent observation of walk-in refrigerator and interview with CDM on 10/3/24 at 11:10 am, observed a rolling food cart filled with multiple trays of uncovered cups of fruit cocktail. CDM acknowledged food in the refrigerator should be covered to avoid infection risk, and ice should not be placed on top of beverage cups as it can water down the beverage. During an interview with DM on 10/3/24 at 11:30 am, DM stated it was an individual choice and not good to put ice on beverage cups to keep them cold. During kitchen observation of tray line on 10/3/24, observed the microwave interior at 11:55 am to reveal moist tan food residue spilled on the bottom and dripped onto the microwave table below it. At 1:15 pm, observed DM remove several utensils with food particles stuck to them from clean silverware containers. DM asked CDM to rewash the utensils and bring clean silverware for resident trays. DM acknowledged the utensils were not clean, which was an infection risk. At 1:25, asked DA K to open the microwave; the spill was still present (90 minutes later). DA K and CDM acknowledged food should be removed immediately after heating and spills cleaned when they happen. DA K and CDM acknowledged the microwave posed a risk for contamination. 3. A review of P&P titled Environment, dated 9/2017, indicated all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary manner and all food contact surfaces will be cleaned and sanitized after use. The P&P indicated the Dining Services Director will ensure: A. The kitchen is maintained in a clean and sanitary manner including floors, walls, ceilings, lighting, and ventilation; B. All employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food service equipment and surfaces; and C. A routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. A review of the 2022 Food Code, US FDA, indicated: A. 4-602.13, Nonfood-Contact Surfaces: The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms, which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. B. 5-205.15, System Maintained in Good Repair: Improper repair or maintenance of any portion of the plumbing system may result in potential health hazards such as cross connections, backflow, or leakage. These conditions may result in the contamination of food, equipment, utensils, linens, or single-service or single-use articles. Improper repair or maintenance may result in the creation of obnoxious odors or nuisances and may also adversely affect the operation of ware washing equipment or other equipment which depends on sufficient volume and pressure to perform its intended functions. C. 6-501.12, Cleaning, Frequency and Restrictions: (1) Physical facilities shall be cleaned as often as necessary to keep them clean, and (2) except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of food is exposed, such as after closing. D. 6-501.14, Cleaning Ventilation Systems, Nuisance and Discharge Prohibition: Intake and exhaust air ducts shall be cleaned, and filters changed so they are not a source of contamination by dust, dirt, and other materials. During concurrent observation on initial kitchen tour and interview with COOK 2 on 10/1/24 at 9:03 am, COOK 2 stated the kitchen is often disgusting on arrival in the morning with food in the sinks, and garbage disposals smell like something died. Observation revealed: A. Kitchen floor with food crumbs, dried gray drip marks, food crumbs and spills between ovens, and a dinner roll under one oven. B. The dry storage room floor was visibly dirty with a brown-black substance, a spill of dried tan substance, and cracked floor tiles. C. A cream-tan colored substance was splashed on the outside of sealed boxes of emergency supply water. D. Floor drains containing brown and black stains, a slimy black substance, plastic bag ties, a plastic cup lid, and paper garbage. E. A fan over the food preparation area and the wall behind it were dusty. During an interview with Maintenance Supervisor (MS) and Certified Dietary Manager (CDM) on 10/1/24 at 10 am, MS stated the internal kitchen floor (in food preparation areas) had recently been redone. MS stated, We need to do [the dry storage room] floor. MS and CDM acknowledged both floors were not clean. During a concurrent observation of the kitchen and interview with Dietary Manager (DM) on 10/2/24 at 5:53 am, observed (unknown) housekeeping staff buffing the dry storage room floor, then leaving the room. On observation of the floor, the spill of dried tan substance observed the previous day was still present under a movable object. DM stated the floor was not clean and she would ask Housekeeping to return. DM stated she had tried but could not remove the stains on emergency water boxes. On observation of the food preparation area, a fan over the sink was dusty, and the wall over the sink revealed gray dust-covered drip marks. The light switch next to the knife holder was visibly soiled with brown residue on the face plate, light switch, and top edge. DM acknowledged these to be infection control issues. During an interview with DM on 10/3/24 at 3:26 pm, DM stated disciplinary actions would be taken regarding the general lack of cleanliness of the kitchen. 4. A review of P&P titled Food: Safe Handling for Foods from Visitors, dated 9/2017, indicated residents will be assisted in properly storing and safely consuming food brought into the facility by visitors . staff will ensure food items intended for later consumption are in a sealed container to prevent cross contamination . foods will be labeled with resident name and current date . refrigerators/freezers will be monitored daily, cleaned weekly, and food items stored greater than or equal to seven days will be discarded. During a concurrent observation of resident refrigerator near nurses' stations and interview with Scheduler and Certified Nurse Assistant Q (CNA Q) on 10/3/24 at 4:47 pm, Scheduler and CNA Q stated resident food should be labeled with resident's name, date opened, and expiration date. Scheduler and CNA Q stated foods should not be in the refrigerator for more than 3 days after opening. Observation indicated an unlabeled bag of shriveled strawberries and a bag of brown wilted salad containing green liquid, which were both wet to touch on the outside of the bag. The freezer contained a small unlabeled cup of what appeared to be frozen yogurt that had melted and refrozen. Scheduler and CNA Q acknowledged the expired and unlabeled food items should have been discarded as they had the potential to expose residents to bacteria that cause foodborne illness. During an interview with Infection Preventionist (IP) Nurse on 10/3/24 at 4:58 pm, IP stated night-shift nursing staff is responsible for cleaning the refrigerator daily. During an interview with Director of Nursing (DON) on 10/4/24 at 8:56 am, DON stated she was told the night-shift nurses were responsible for cleaning the resident refrigerator. DON stated the IP Nurse supervises cleaning. During an interview with DON on 10/8/24 at 10:32 am, DON stated CDM informed her the kitchen was responsible for cleaning the resident refrigerator, and the kitchen should have those cleaning logs. During an interview with CDM on 10/8/24 at 11:17 am, CDM stated Housekeeping cleans the resident refrigerator and would have those cleaning logs. During an interview with Housekeeping Manager (HSK M) on 10/8/24 at 11:20 am, HSK M stated the utility room (where resident refrigerator is located) is cleaned and sanitized daily, but food is cleaned out by kitchen staff. HSK M stated Housekeeping does a deep clean inside once a month and cleans the exterior and handles daily. HSK M stated cleaning logs had been provided to surveyors on 10/4/24. September resident refrigerator/freezer temperature logs were received; cleaning logs were not.

Mar 2024 7 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Respiratory Care (Tag F0695)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) received respiratory care when a physician ordered Bilevel Positive Airway Pressure (BiPAP-a device that helps breathing) was not implemented for 14 days. This resulted in an emergent transfer to hospital for treatment for severe respiratory failure (not enough oxygen) for five days. Findings: A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and Congestive Heart Failure (CHF, weak heart causes fluid buildup). During her hospitalization she was started on BiPAP-a breathing machine. Resident 1 was transferred to a long-term care facility on 12/29/2023. During a review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of facility policy titled CPAP/BiPAP Support and Cleaning, dated March 2015, indicated only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. A resident ' s medical record should be reviewed to determine his/her baseline oxygen saturation (amount of oxygen that's circulating in your blood), respiratory, circulatory status. The physician ' s order should be reviewed to determine the oxygen concentration and flow and pressure settings for the machine. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). A record review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. A review of Resident 1 ' s record dated from 12/29/23 to 1/16/24, indicated there was no documentation found that nursing staff called the physician to verify if Resident 1 was to continue the BiPAP machine. A review of a document titled Order Summary, indicated that there was an oxygen order dated 12/29/2023, for Resident 1 to receive 3 liters via nasal cannula (a flexible tube worn under the nose delivering oxygen) or shortness of breath, as needed. A review of document titled Weights and Vitals Summary for January 2024, Resident 1 had been receiving supplemental oxygen via nasal cannula from 1/6/2024 to 1/11/2024 during the day, and room air only from 1/11/2024 to 1/13/2024 at night. Resident 1 received BiPAP at bedtime only from 1/12/24 to 1/16/2024. A review of document titled Minimum Data Set (MDS is a tool for implementing standardized assessment and facilitating care management in nursing homes) dated 1/5/2024, by MDS Registered Nurse (MDS RN) no documentation for BiPAP was found in the record. A review of a Care Conference note dated 1/12/2024, a meeting was held between Responsible Party (RP, decision maker), Social Services Director (SSD), Director of Nursing (DON), and Administrator (Admin). RP expressed a concern that Resident 1 was not receiving BiPAP. After the care conference concluded, RP called SSD and repeated her concerns. SSD and Admin approached LVN 1 and questioned where the BiPAP machine was located. LVN 1 and Admin went to Resident 1 ' s room and could not locate the machine. LVN 1 located BiPAP in Resident 1 ' s closet in a pink bag. A review of a physician order dated 1/12/24, 14 days after admission, the BiPAP was ordered with settings for Resident 1, the oxygen saturation level should be at 90- 92%, at bedtime for sleep apnea (breathing starts and stops during sleep). During a review of a Progress Notes dated 1/15/2024, at 1:19 pm, Social Services Assistant (SSA) documented Resident 1 declined a room visit and stated she was not feeling well. There was no indication in the documentation that nursing staff performed an assessment of her overall status. During a review of document titled Change in Condition (SBAR) assessment dated [DATE] at 10:18 am, indicated the reason for the SBAR was Resident 1 was experiencing shortness of breath (SOB) and her oxygen saturation level was 76 % (oxygen saturation levels below 90% can lead to a serious deterioration in health status) when receiving oxygen via nasal cannula. The Medical Director (MDir) was notified. During a review a progress note on 1/16/2023 at 1:26 pm, RN 1 documented that an order was received to transfer Resident 1 to the hospital due to SOB. On 1/16/2024 at 2:50 pm, Assistant Director of Nurses (ADON) documented Resident 1 ' s oxygen saturation decreased. Nurse Practitioner (NP) notified; orders received to transfer Resident 1 to hospital. No further documentation was found in Resident 1 ' s record for ongoing assessment of oxygen saturation from 10:23 am until five hours later at 3:02 pm, done at the hospital. During an interview on 1/25/2024 at 10:40 am, the admission Supervisor (AS) stated the process for admissions was the case manager at the hospital would send her the resident ' s referrals and orders. AS stated, after receiving the information she sends it to Director of Nursing (DON), Assistant Director of Nursing (ADON), nursing staff and therapy departments via email and uploads the orders into the Electronic Medical Record (EMR). AS stated, that on 12/28/2023, Resident 1 ' s orders came by fax on several pieces of paper. AS explained orders would be emailed to the admission nursing staff. AS stated, a separate fax was received from the hospital with orders containing the settings for a BiPAP machine. AS stated, she did not think she needed to give this to the nursing staff and faxed the order to Interactive Medical Services (IMS-medical device supply company). AS reported, she did not email, print, or upload the faxed BiPAP order and settings into the electronic medical record that admissions, nursing staff, and medical director have access to. During a phone interview on 1/25/2024 at 11 am, the Interactive Medical Services representative (IMS-R, a BiPAP equipment rental agency) stated Resident 1 ' s BiPAP machine was delivered to the facility with preset settings on 12/29/2023 at 3:04 pm and was signed for by Licensed Vocational Nurse (LVN) 2. During an interview on 1/25/2024 at 2:40 pm, LVN 2 stated she had six admissions on 12/29/2023, it was very hectic. LVN 2 stated that she felt so overwhelmed with six admissions that she told ADON she would quit if they accepted a seventh admission. LVN 2 stated she remembered signing for Resident 1 ' s BiPAP machine and putting it at Resident 1 ' s bedside. LVN 2 stated that DON and Admin left at 2 pm that day. During a concurrent interview and record review on 1/25/2024 at 12 pm, Assistant Director of Nursing (ADON) stated he entered BiPAP order and diagnosis on 1/12/2024. ADON confirmed Resident 1 ' s documented diagnosis for the BiPAP was COPD and hypercapnia which utilizes BiPAP to help rid the body of excess carbon dioxide. ADON confirmed Resident 1 ' s BiPAP machine was delivered on 12/29/2024, and that Resident 1 did not use the BiPAP as ordered until 1/12/2024. During an interview on 1/25/2024 at 12:17 am, DON stated her expectations was the nursing staff should have verified physician orders for the BiPAP during the admission process for Resident 1. DON further stated the licensed nursing staff should have followed up when the BiPAP machine delivered and set up in Resident 1's room. DON stated licensed nurses should complete and document all respiratory assessments in the record when there was a change in condition. During interview on 1/25/2024 at 1:55 pm, SSD stated Resident 1 ' s RP called her on 1/12/24, and inquired about the BiPAP machine that her mother should have had since admission. SSD stated she called the RP later stating the BiPAP was found and now at Resident 1's bedside. A review of a hospital Discharge summary dated [DATE] at 10:16 am, the physician indicated Resident 1 was brought in by ambulance on 1/16/24, with increasing fatigue and altered mental status (changes in mood/cognitive function). Physician documented Resident 1 was found to have significant hypercapnia and was admitted to a step down unit for acute respiratory failure, COPD exacerbation, large pleural effusion (build up of fluid around and in lung tissue), pulmonary edema (too much fluid in lungs, and CHF exacerbation (worsening). Resident 1 was discharged from the hospital on 1/31/24, after five days. During a concurrent interview and record review on 2/7/2024 at 9:19 am, DON confirmed that in Resident 1 ' s admission Assessment document dated 12/29/2023 there was no BiPAP noted. DON confirmed there was no BiPAP documentation on Resident 1 ' s Baseline Care Plan dated 12/29/2023. DON confirmed that Resident 1 ' s BiPAP was not ordered by MDir until 1/12/2024, 14 days after admission. DON confirmed Resident 1 ' s hospital Discharge Summary was not scanned into EMR. During a phone interview on 2/14/2024 at 9:47 am, Medical Records Director (MRD) stated on the day of Resident 1 ' s admission on [DATE], there were six admissions. MRD stated that three admissions were their average and there had only been two occasions in the last eight years where there were six admissions. MRD stated that the staff was panicked, left in a scramble, was not prepared for the influx of residents, and felt abandoned. MRD stated that the Admin, DON, the business representative, and admissions staff left early that day. When asked if she saw Resident 1 ' s order for BiPAP, she confirmed that she was unaware of the BiPAP order. During a concurrent interview and record review on 2/14/2024 at 11:30 am, MDS RN confirmed Resident 1 ' s BiPAP was not in initial care plan. MDS RN stated Resident 1 ' s hospital discharge summary should have been scanned into EMR and given to the admissions nurse. MDS RN confirmed it could not be found in EMR and stated she was unaware Resident 1 ' s BiPAP was ordered and delivered at bedside. During a phone interview on 2/14/2024 at 10:13 am, MDir stated he was not responsible for how many admissions a facility would receive, but that six admissions in one day would be unusual. MDir stated the admissions coordinator puts everything into the EMR (which he has access to) including discharge records from hospital, which he reads after admission is finalized. When told that AS had the order for the BiPAP prior to admission and that it did not come in until 14 days post admission, MDir stated AS should have relayed that to DON or ADON. MDir stated he did not know how any of that happened. Regarding Resident 1 not feeling well after not receiving ordered BiPAP for 14 days, MDir stated if she wasn ' t doing well, what could happen, did happen. Carbon dioxide goes up, then she would eventually become lethargic, and comatose.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency 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 record review the facility failed to ensure that one of four residents (Resident 1) was educated, informed and allowed to make her own medical decisions before administering a psychotropic (alters mood and behavior). This failure resulted in Resident 1 to receive an unnecessary medication and had the potential for adverse effects such as sedation, dry mouth, weakness, headaches, dizziness, nausea and being unable to sleep. Refer to F758. Findings: A review of a facility policy titled Informed Consent Policy, undated, under documentation form, indicated This verification that informed consent was given shall be made available to the facility from either the person who obtained the consent (physician or nurse practitioner - only if they were the one who prescribed the medication) or who gave the consent (patient/resident, or responsible party, if patient/resident is not capable) in either verbal, FAX, e-mail, or document (copy or original). The facility staff who are authorized to take such orders shall either document or include the printed or electronic version of the IC with the patient's medical record. Informed consent policy under procedure: When a medication is going to be used in a psychotherapeutic manner the facility will need to verify from the physician or their office staff that IC has been obtained .The facility will need to obtain the indication for use from the physician. The facility provided its informed consent policy, which states that The facility shall verify that informed consent (IC) has been obtained by the physician before a psychotherapeutic medication is administered except the it is deemed to be an emergency situation, or the resident refuses to want to know or the physician deems the information contained in the IC would be too disturbing. Resident 1 was admitted to the facility on [DATE], with diagnoses including heart failure, acute and chronic respiratory failure with hypercapnia (a disease affecting the lungs ability to remove carbon dioxide or deliver oxygen to your blood) and chronic obstructive pulmonary disease (COPD) with acute exacerbation and bronchitis due to respiratory syncytial virus (COPD refers to a group of diseases that cause airflow blockage and breathing related problems complicated by a respiratory infection) and cognitive communication deficit (difficulty communicating, thinking, remembering and responding accurately). A review of a hospital Discharge summary dated [DATE], indicated Resident 1 was able to give a clear history and was not taking any psychotropic medications. A review of a Preadmission Screening and Resident Review (PASRR-screening for mental illness) dated 12/20/2023, Resident 1 had no diagnoses for mental disorders such as Depressive Disorder, Anxiety Disorder and had not been prescribed any psychotropic medications. A review of Skilled Charting dated: 12/29/2023, 12/30/2023, 12/31/2023, 1/1/2024, 1/2/2024, 1/04/2024, 1/05/2024, 1/06/2024 (at 12:03 am), 1/06/2024 (at 12:42 pm), 1/08/2024, 1/09/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, indicated Resident 1 had no changes to mood and behavior. A review of document titled Weekly Progress Notes dated 12/31/2023, Licensed Vocational Nurse (LVN 1) documented Resident 1 had no changes in behavior or mood, was alert and oriented, able to make her needs known, had no complaints, no signs of distress and was adjusting well to the new environment. A review of Progress Notes dated 12/31/2023, 12/30/2023, 12/29/2023, indicated Resident 1 was adjusting well, no signs of distress, no changes in behavior and able to verbalize her needs. A review of document titled Minimum Data Set (MDS-a resident assessment and care screening tool) dated 1/05/2024, by MDS Registered Nurse (MDS RN) documented that Resident 1 was not considered to have a serious mental illness, there was no evidence of an acute change in mental status. A review of document titled Progress Notes dated 1/03/2024 at 1:04 am, RN 3 documented Resident 1 was awake and alert, able to tell her needs, no complaints reported. A review of document titles Progress Notes dated 1/06/2024 at 12:52 pm, RN 1 documented Resident 1 had no signs of distress and no complaints reported. A review of document titled Weekly Progress Note dated 1/07/2024, RN 1 documented Resident 1 was awake and alert, had no changes in behavior or mood, was not on psychoactive medication and had no signs of distress. A review of document titled Progress Notes dated 1/11/2024 at 8:40 pm, Activities Assistant documented that Resident 1 enjoyed watching true crime stories and was happy. A review of document titled Progress Note, alert note, on 1/11/2024 at 1:30 pm, by Assistant Director of Nursing (ADON) documented Nurse Practitioner (NP) in to see Resident 1, Lexapro (antidepressant) for depression ordered 5 milligrams (mg) daily. A review of Resident 1's record indicated no nursing progress note by ADON nor any physician or NP notes found in the record to indicate the clinical justification for the Lexapro. A review of document titled Weekly Progress Note dated 1/14/2024, RN 2 documented Resident 1 had no changes in behavior or mood, verbalizes needs and continued Lexapro. During a phone interview on 2/14/2024 at 10:39 am, ADON stated he remembered Resident 1. ADON stated he could not recall the medical reason Resident 1 was started on a psychotropic. ADON stated that nothing in [his] mind makes [him] recall that she needed Lexapro. ADON stated that if he puts in an order for psychotropic medication, he does the informed consent right then. When told that no consent for the psychotropic medication could be found in the medical record, he stated he fills out the consent and the doctor review it, then it goes to medical records. ADON was unable to find or provide informed consent or nursing progress notes that it was given to Resident 1. During a phone interview on 2/14/2024 at 10:02 am, Medical Director (MDir) stated the Interdisciplinary Team (IDT, a group of multidisciplinary team members who discuss resident plan of care) meet to discuss residents who are on psychotropic medications. MD stated there needs to be a clinical reason documented and discussed before starting a psychotropic, including informed consent (discuss risks and benefits) of a medication.

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to create an accurate comprehensive admission assessment for one four sampled residents (Resident 1) when a physician ordered treatment for a Bilevel Positive Airway Pressure (BiPAP-a device to help breathing) was not identified. This resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) requiring a transfer to a hospital for emergent treatment. Findings: A review of a facility policy titled Resident Assessments F636; F637; F638 undated, indicated a comprehensive assessment of each resident is completed at intervals. Comprehensive admission Minimum Data Set (MDS, resident assessment) include Care Area Assessment (CAA) process for resident care planning. Information for the MDS assessments will consistently reflect information in the progress notes, plans of care, and resident observations/interviews. A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and congestive heart failure. During her hospitalization she was started on BiPAP. Resident 1 was transferred to a long-term care facility on 12/29/2023. During a review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). A review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. A review of document titled Baseline Care Plan -WH-, which took place on 12/30/2023, Minimum Data Set Registered Nurse (MDS RN) indicated Resident 1 could communicate her needs with the staff and was oriented. MDS RN checked the box 1a under special treatments, procedures and program that Resident 1 would need oxygen therapy - while a resident. MDS RN did not check the box 1e in the assessment to indicate that Resident 1 would need BiPAP/CPAP. A review of the admission MDS dated [DATE], indicated under Section O G1, BiPAP was not selected and C3 indicated oxygen therapy was intermittent. A review of a respiratory care plan dated 1/1/24, and updated 1/22/24, indicated no interventions related to the management of the BiPAP for Resident 1. During a concurrent interview and record review on 2/14/2024 at 11:30 am, MDS RN confirmed Resident 1 ' s BiPAP was not included in the admission MDS. MDS RN stated Resident 1 ' s hospital discharge summary should have been scanned into the electronic medical record and given to admissions nurse. MDS RN stated she was unaware Resident 1 ' s BiPAP was ordered/delivered to her room.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to create a baseline care plan that included a respiratory treatment for one four sampled residents (Resident 1) when she did not receive her physician ordered Bilevel Positive Airway Pressure (BiPAP-a device that helps breathing). This resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) requiring a transfer to a hospital for emergent treatment. Findings: A review of a policy and procedure titled Care Plans - Baseline - F655, revised March 2022, indicated that the baseline care plan includes instructions needed to provide effective, person-centered care of the resident .must include the minimum healthcare information necessary to properly care for the resident including .physician orders. The baseline care plan is used until the staff can conduct the comprehensive assessment and develop a comprehensive care plan to meet the needs of the resident. A baseline care plan includes but not limited to any services and treatments to be administered by the facility personnel. A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes, memory loss, confusion and altered consciousness) and congestive heart failure. During her hospitalization she was started on BiPAP. Resident 1 was transferred to a long-term care facility on 12/29/2023. A review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). A review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. During a concurrent interview and record review of a Baseline Care Plan -WH dated, 12/30/2023, the Minimum Data Set Registered Nurse (MDS RN) confirmed Resident 1 ' s BiPAP was not included in the baseline care plan. MDS RN confirmed she checked the box 1a under special treatments, procedures, and program that Resident 1 would need oxygen therapy - while a resident. MDS RN did not check the box 1e in the assessment to indicate that Resident 1 would need BiPAP/CPAP. MDS RN stated she did not create the baseline care plan assessment at the bedside because Resident 1 was admitted on a 12/29/23, and the care plan needed to be completed within 48 hours of admission. MDS RN stated she was unaware of the fax order dated 12/29/23.

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

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 and record review, the facility failed to ensure that one of four residents (Resident 1) was free of an unnecessary psychotropic medication (drug prescribed to affect the mind, emotions, or behavior) when she was prescribed Lexapro (medication used to treat depression and anxiety) was administered without clinical indication. This failure resulted in Resident 1 to receive an unnecessary medication and put her at risk for adverse side effects such as sedation, dry mouth, weakness, headaches, dizziness, nausea and being unable to sleep. Refer to F552. Findings: A review of facility policy titled Psychotropic Medication Use, dated July 2022, indicated the use of any psychotropic medication is based on comprehensive review of the resident. Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record. A review of facility policy titled Informed Consent Verification, undated, indicated the facility shall verify that informed consent (IC) has been obtained by the physician before a psychotherapeutic medication is administered. When a medication is going to be used in a psychotherapeutic manner the facility will need to verify from the physician or their office staff that IC has been obtained and will need to obtain the indication for use from the physician. The facility staff who are authorized to take such orders shall either document or include the printed or electronic version of the IC with the resident ' s medical record. Resident 1 was admitted to the facility on [DATE], with diagnoses which included heart failure, acute and chronic respiratory failure with hypercapnia ( a disease affecting the lungs ability to remove carbon dioxide or deliver oxygen to your blood) and chronic obstructive pulmonary disease (COPD) with acute exacerbation and bronchitis due to respiratory syncytial virus (COPD refers to a group of diseases that cause airflow blockage and breathing related problems complicated by a respiratory infection) and cognitive communication deficit (difficulty communicating, thinking, remembering and responding accurately). A review of a Discharge Summary from the local hospital dated 12/29/2024, Resident 1 was noted to be able to give a clear history and was not taking any psychotropic medications. A review of hospital document titled Preadmission Screening and Resident Review (PASRR-a pre-admission screening for mental illness performed by the hospital before discharge) dated 12/20/2023, Resident 1 had no diagnoses for mental disorders such as Depressive Disorder, Anxiety Disorder and had not been prescribed any psychotropic medications. A review of Progress Notes dated 12/31/2023, 12/30/2023, 12/29/2023 and 1/3/24, Resident 1 was documented as adjusting well, no signs of distress, no changes in behavior and able to verbalize her needs. A review of facility ' s documents titled Skilled Charting dated: 12/29/2024, 12/30/2024, 12/31/2024, 1/1/2024, 1/2/2024, 1/04/2024, 1/05/2024, 1/06/2024 (at 0:03 am), 1/06/2024 (at 12:42 pm), 1/08/2024, 1/09/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2023, 1/15/2023 all the documents indicated Resident 1 had no changes in her mood and behavior. A review of Weekly Progress Notes dated 12/31/2023, Licensed Vocational Nurse (LVN) 1 documented Resident 1 had no changes in behavior or mood, was alert and oriented, able to make her needs known, had no complaints, no signs of distress and was adjusting well to the new environment. A review of a Minimum Data Set (MDS-a resident assessment and care screening tool) dated 1/05/2024 by MDS RN documented that Resident 1 was not considered to have a serious mental illness, there was no evidence of an acute change in mental status. A review of Progress Notes dated 1/06/2024 at 12:52 pm, Registered Nurse (RN) 1 documented Resident 1 had no signs of distress and no complaints reported. A review of Weekly Progress Note dated 1/07/2024, RN 1 documented Resident 1 was awake and alert, had no changes in behavior or mood, was not on psychoactive medication and had no signs of distress. A review of an Order Details dated 1/11/2024 at 1:26 pm, by Nurse Practitioner (NP) indicated Escitalopram Oxalate (Lexapro) 5 mg once daily by mouth for depression. This order was documented as created and confirmed by Assistance Director of Nursing (ADON) on 1/11/2024 at 1:26 pm. A review of a Progress Note, alert note, on 1/11/2024 at 1:30 pm, by ADON documented Nurse Practitioner (NP) in to see Resident 1, probiotics ordered, Lexapro for depression ordered 5 mg daily. No documentation or clinical indications were found indicating Resident 1 was depressed. No Interdisciplinary Team (IDT-a meeting of health care team members to coordinate resident treatment/care) meeting notes indicating Resident 1 was depressed. No informed consent for psychotropic drugs were found in record. A review of a Weekly Progress Note dated 1/14/2024, RN 2 documented Resident 1 had no changes in behavior or mood, verbalizes needs and continues Lexapro. A review a Progress Notes dated 1/11/2024 at 8:40 pm, Activities Assistant documented that Resident 1 enjoyed watching true crime stories and was happy. During a phone interview on 2/14/2024 at 10:39 am, ADON stated he could not recall the clinical need for Resident 1 to be taking a psychotropic drug. ADON stated that if he puts in an order for psychotropic medication, he does the informed consent right then. When told that no consent for the psychotropic medication could be found in the medical record, he stated he fills out the consent and the doctor review it, then it goes to medical records. ADON was given the opportunity to send this office a copy of the informed consent. No consent has been received. During a phone interview on 2/14/2024 at 10:02 am with Medical Director (MDir) stated, usually the Interdisciplinary Team (IDT, a group of multidisciplinary team members who discuss resident plan of care) meet to discuss residents who are on psychotropic medications. MDir stated there needs to be a clinical reason documented and discussed before starting a psychotropic, including informed consent (discuss risks and benefits) of a medication. When told that there was no indication in her medical record that Resident 1 was depressed, MDir stated that may have just been bad judgement by the Nurse Practitioner.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0841 (Tag F0841)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the Medical Director (MD) supervised the development and implementation of a plan of care for one of four sampled residents (Resident 1) when: 1. Upon admission orders for BiPAP (device to help breathing) were not implemented. Refer to F 695 2.a. Informed consent was not obtained before administering a psychotropic (alters mood behavior) medication. Refer to F 552 b. An unnecessary psychotropic was prescribed without clinical justification. Refer to F 758 This failure resulted in respiratory failure that required emergent hospitalization and an unnecessary psychotropic medication to be administered without clinical justification. Findings: A review of a facility policy titled Medical Director revised July 2016, indicated physician services are under the general supervision of the Medical Director (MD). The MD was responsible for ensuring adequate and appropriate physician services. MD was to oversee and help develop and implement care related policies and practices. MD to participate in efforts to improve quality of care and services. MD to help assure residents receive services to meet their needs by assuring resident care plan reflects the medical regimen. 1. A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and congestive heart failure. During her hospitalization she was started on bilevel positive airway pressure (BiPAP-a breathing machine that delivers positive air pressure when you breathe in and out). Resident 1 was transferred to a long-term care facility on 12/29/2023. A review of hospital document titled Discharge Planning Needs sent to facility from hospital dated 12/29/2023 at 3:16 pm, by Case Manager Social Worker (CM/SW, coordinates care between hospital and care facility) indicated Resident 1 ' s discharge plan to facility was discussed with Resident 1 ' s family member how important it was for Resident 1 for the facility was to supply BiPAP for patient. A review of facility policy titled CPAP/BiPAP Support and Cleaning, dated March 2015, indicated only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. A resident ' s medical record should be reviewed to determine his/her baseline oxygen saturation, respiratory, circulatory status. The physician ' s order should be reviewed to determine the oxygen concentration and flow and pressure settings for the machine. A review of hospital document titled Discharge Summary, and Order Sheet indicated that the primary discharge packet was sent via fax by the hospital and received by the long-term care facility at 3:01 pm and 3:05 pm on 12/28/2023. A review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (amount of oxygen in blood, normal is 95-100%). A review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. A review of Resident 1 ' s record, there was no documentation found that nursing staff called the physician to verify if Resident 1 was to continue the BiPAP machine as documented in Resident 1 ' s discharge summary. A review an Order Summary, indicated that there was an oxygen order dated 12/29/2023, for Resident 1 to receive 3 liters via nasal cannula (a flexible tube worn under the nose delivering oxygen) or shortness of breath, as needed. A reviewWeights and Vitals Summary for January 2024, Resident 1 had been receiving supplemental oxygen via nasal cannula from 1/6/2024 to 1/11/2024 during the day, and room air only from 1/11/2024 to 1/13/2024 at night. Resident 1 received BiPAP at bedtime only from 1/12/24 to 1/16/2024. A review of a physician order dated 1/12/24, 14 days after admission, the BiPAP was ordered with settings 40, 92, AS 14/6, BUR 10, titrate oxygen saturation at 90- 92% at bedtime for sleep apnea (breathing starts and stops during sleep). A review of a Change in Condition (SBAR) assessment dated [DATE] at 10:18 am, indicated the reason for the SBAR was Resident 1 was experiencing shortness of breath (SOB). Medical Director (MDir) was notified. A review a progress notes on 1/16/2023 at 1:26 pm, RN 1 documented that an order was received to transfer Resident 1 to the hospital due to SOB. On 1/16/2024 at 2:50 pm, Assistant Director of Nurses (ADON) documented Resident 1 ' s oxygen saturation decreased. Nurse Practitioner (NP) notified; orders received to transfer Resident 1 to hospital. No further documentation was found in Resident 1 ' s record for ongoing assessment of oxygen saturation from 10:23 am until five hours later at 3:02 pm, done at the hospital. A review of a hospital Discharge summary dated [DATE] at 10:16 am, the physician indicated Resident 1 was brought in by ambulance on 1/16/24, with increasing fatigue and altered mental status (changes in mood/cognitive function). Physician documented Resident 1 was found to have significant hypercapnia and was admitted to a step down unit for acute respiratory failure, COPD exacerbation, large pleural effusion (build up of fluid around and in lung tissue), pulmonary edema (too much fluid in lungs, and CHF exacerbation (worsening). Resident 1 was discharged from the hospital on 1/31/24, after five days. 2.A review of a hospital Discharge summary dated [DATE], indicated Resident 1 was able to give a clear history and was not taking any psychotropic medications. A review of a Preadmission Screening and Resident Review (PASRR-screening for mental illness) dated 12/20/2023, Resident 1 had no diagnoses for mental disorders such as Depressive Disorder, Anxiety Disorder and had not been prescribed any psychotropic medications. A review Minimum Data Set (MDS-a resident assessment and care screening tool) dated 1/05/2024, by MDS Registered Nurse (MDS RN) documented that Resident 1 was not considered to have a serious mental illness, there was no evidence of an acute change in mental status. A review of Skilled Charting dated: 12/29/2023, 12/30/2023, 12/31/2023, 1/1/2024, 1/2/2024, 1/04/2024, 1/05/2024, 1/06/2024 (at 12:03 am), 1/06/2024 (at 12:42 pm), 1/08/2024, 1/09/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/13/2024, 1/14/2024, 1/15/2024, indicated Resident 1 had no changes to mood and behavior. A review of document titled Progress Note, alert note, on 1/11/2024 at 1:30 pm, by Assistant Director of Nursing (ADON) documented Nurse Practitioner (NP) in to see Resident 1, Lexapro (antidepressant) for depression ordered 5 milligrams (mg) daily. A review of Resident 1's record indicated no nursing progress note by ADON nor any physician or NP notes found in the record to indicate the clinical justification for the Lexapro. During a phone interview on 2/14/2024 at 10:13 am, Medical Director (MDir) stated he was not responsible for how many admissions a facility would receive, but that six admissions in one day would be unusual. MDir stated the admissions coordinator puts everything into the Electronic Medical Record (EMR, which he has access to) including discharge records from hospital, which he reads after admission was accepted. When told that AS had the order for the BiPAP prior to admission and that it did not come in until 14 days post admission, MDir stated AS should have relayed that to DON or ADON. MDir stated he did not know how any of that happened. Regarding Resident 1 not feeling well after not receiving ordered BiPAP for 14 days, MDir stated if she wasn ' t doing well, what could happen, did happen. Carbon dioxide goes up, then she would eventually become lethargic, and comatose. MDir stated, usually the Interdisciplinary Team (IDT, a group of multidisciplinary team members who discuss resident plan of care) meet to discuss residents who are on psychotropic medications. MDir stated there needs to be a clinical reason documented and discussed before starting a psychotropic, including informed consent (discuss risks and benefits) of a medication. When told that there was no indication in her medical record that Resident 1 was depressed, MDir stated that may have just been bad judgement by the Nurse Practitioner.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure enough nursing staff had the appropriate competencies and skills to implement a respiratory plan of care for one of four sampled resident (Resident 1). This failure resulted in a decline in Resident 1 ' s respiratory and metabolic status (a condition where the decline of the lung function negatively affects the functioning of the rest of the body) resulting in emergent transfer to a hospital for treatment. Refer to F695. Findings: A review of facility policy titled CPAP/BiPAP Support and Cleaning dated March 2015, indicated only a qualified and properly trained nurse or respiratory therapist should administer oxygen through a CPAP/BiPAP mask. A resident ' s medical record should be reviewed to determine his/her baseline oxygen saturation, respiratory, circulatory status. The physician ' s order should be reviewed to determine the oxygen concentration and flow and pressure settings for the machine. A review of Resident 1 ' s hospital Discharge summary dated [DATE] at 1:08 pm, indicated she had been hospitalized for 9 days for treatment of acute respiratory failure with hypercapnia (respiratory system fails and carbon dioxide [a gas by product that is removed from the body by exhalation] builds up in the body), chronic obstructive pulmonary disease (COPD-a condition of the respiratory system causing shortness of breath, cough, fatigue and frequent lung infections), toxic metabolic encephalopathy (a condition of acute brain dysfunction resulting in seizures, behavior changes , memory loss, confusion and altered consciousness) and congestive heart failure. During her hospitalization she was started on bilevel positive airway pressure (BiPAP-a breathing machine that delivers positive air pressure when you breathe in and out). Resident 1 was transferred to a long-term care facility on 12/29/2023. During a review of hospital order sheet faxed to the long-term care facility dated 12/29/2023 at 11:25 am, indicated a hospital medical doctor ordered BiPAP on at bedtime and off for 6 hours during the day to keep her oxygen level above 90-92% (normal is 95-100%). During a record review of an admission assessment dated [DATE] at 5:42 pm, by Licensed Vocational Nurse (LVN) 1, no documentation of Resident 1 ' s need for BiPAP was noted. During a review of a document titled Order Summary, indicated that there was an oxygen order dated 12/29/2023, for Resident 1 to receive 3 liters via nasal cannula (a flexible tube worn under the nose delivering oxygen) or shortness of breath, as needed. A review of a physician order dated 1/12/24, 14 days after admission, the BiPAP was ordered with settings 40, 92, AS 14/6, BUR 10, titrate oxygen saturation at 90- 92% at bedtime for sleep apnea (breathing starts and stops during sleep). During concurrent interview and record review on 1/24/2024 at 11:30 am with Director of Staff Development (DSD-person in charge of planning employee training and professional development classes), she confirmed she could not produce any documentation of in-services/instruction to staff for BiPAP use. DSD confirmed that physician order for BiPAP was in the Resident 1 ' s record on 12/29/2024 but did not show up in active orders (orders that instruct nurses how to care for residents) until 1/12/2024. During interview on 1/24/2024 at 2:28 pm with Licensed Vocational Nurse Infection Preventionist (LVN-IP) stated she has not had any training on using BiPAP machines. During an interview on 1/25/2024 at 10:30 am with LVN 7, LVN 5 at 10:40 and LVN 1 at 3:15 pm, all reported having no in-services for BiPAP. During an interview on 1/25/2024 at 12:17 am, DON stated her expectations was the nursing staff should have verified physician orders for the BiPAP during the admission process for Resident 1. DON further stated the licensed nursing staff should have followed up when the BiPAP machine delivered and set up in Resident 1's room. DON stated licensed nurses should complete and document all respiratory assessments in the record when there was a change in condition. DON confirmed there were no in-services/training on the use of BiPAP machines. During a concurrent interview and record review on 2/7/2024 at 9:19 am, DON confirmed that in Resident 1 ' s admission Assessment document dated 12/29/2023 there was no BiPAP noted. DON confirmed there was no BiPAP documentation on Resident 1 ' s Baseline Care Plan dated 12/29/2023. DON confirmed that Resident 1 ' s BiPAP was not ordered by MDir until 1/12/2024, 14 days after admission. DON confirmed Resident 1 ' s hospital Discharge Summary was not scanned into electronic medical record so all staff have access to it.

Jun 2023 27 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident 48) who entered the facility without a pressure ulcer (PU), did not develop a pressure sore and that the resident received necessary care and services to promote healing, when Resident 48 was at a risk for PU's upon admit and routine skin assessments did not identify the pressure ulcer at an early stage. Resident 48's PU was identified on 4/7/23 at stage 3 (full thickness tissue loss without muscle, tendon, or bone visible). Resident 48's PU was not evaluated and treated by a wound care physician for 40 days and progressed to a stage 4 PU (a pressure injury that extended through the skin to muscle, tendon, or bone) on 5/18/23. This failure resulted in Resident 48 developing a stage 3 pressure ulcer to her coccyx (a bone at the base of the spine), which was further staged at a stage 4 PU by a wound doctor (WD, a physician that specializes in healing wounds), accompanying a severe weight loss. Refer F692 Findings: A facility policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, with a revised date of April 2018, indicated, The physician will order pertinent wound treatments, including pressure reduction surfaces . The physician will help identify medical interventions related to wound management; for example . addressing comorbid (medical conditions that are simultaneously present in a patient) medical conditions, managing pain related to the wound or to wound treatment, etc. A review of the facility's records indicated Resident 48 was admitted to the facility on [DATE], with diagnoses that included difficulty in walking, cognitive communication deficit (difficulty with thinking and how someone uses language), age related osteoporosis (bone disease that can lead to a decrease in bone strength), muscle weakness, and Parkinson's disease (a progressive nerve disorder resulting in tremors, stiffness, dementia). A review of a minimum data set (MDS, a tool for implementing standardized assessment and for facilitating care management in nursing homes) dated 07/22/2022, upon admission to the facility, indicated, Resident 48 was at risk of developing pressure ulcers/injuries and did not have one or more unhealed pressure ulcers/injuries at that time of admission to the facility. A review of a weekly progress note dated 04/02/2023 at 3:10 PM, indicated, No new skin issues noted this week. A review of a nursing progress note dated 04/07/2023 at 4:13 PM, indicated, Writer was notified by CNA (Certified Nursing Assistant) who had worked with resident yesterday PM shift, of resident having an open area to their coccyx. Writer assessed the area and noted the following: - Open area to coccyx measuring 2.5 centimeters (cm, a unit of measure) x 2 cm with slough (dead tissue) present at wound bed . Upon inquiring from staff, resident has been known to remain in supine position (face up, laying on back) and refusing to be turned by staff . A review of a nursing progress note dated 04/07/2023 at 9:42 PM, indicated, Treatment (Tx) nurse notified resident has open area to coccyx measuring 2.5 cm x 2cm with slough present at wound bed . Tx done by Tx nurse . A review of a document titled, Weekly Non-Pressure Skin Report, indicated on the week of 04/19/2023 Resident 48 had a new, excoriation (a well-defined injury with sharp or linear edges) to her coccyx. There was no documentation provided for the week of 04/12/2023 on this document. A review of a document titled, treatment administration report (TAR), dated March 2023, indicated, No order data found for Treatment Administration Record. A review of a document titled TAR, dated April 2023, indicated treatment for the wound on the coccyx began on 04/08/2023 by the treatment nurse. A review of a document titled, Comprehensive CNA Shower Review, for Resident 48 dated between 03/10/2023 to 05/1/2023 indicated, out of nine sheets provided, the resident had one shower sheet that indicated she had a pressure ulcer. The shower sheet that indicated CNA A had observed a tear at the lower coccyx on Resident 48 on 04/18/2023, but the three sheets following that date did not have any indication of an open area, wound, or tear. A review of a nursing progress note dated 04/10/2023 at 9:37 AM, indicated Resident 48, Is incontinent of bowel and bladder and does not know when she needs her brief changed. She is almost entirely dependent for movement and positioning. Staff educated to check brief and reposition/offload points of pressure at least every 2 hours and as resident will tolerate. (Resident 48) is at risk for skin breakdown due to her age, impaired mobility, incontinence, muscle weakness, and other comorbidities . A review of a weekly progress note dated 04/16/2023 at 1:54 AM, indicated, there are no current skin alterations. The comments section of the document indicated, Resident stable this week. No new changes noted. All needs met by staff . A review of a MDS dated [DATE], indicated Resident 48 was frequently incontinent of bowel and bladder. The document further indicated that the resident does not have a current pressure ulcer/injury but was at risk of developing pressure ulcers/injuries. A review of section G of the MDS, for the resident's functional status, it indicated that resident 48 required extensive assistance with bed mobility, which included how the resident moved, turned, and repositioned body while in bed. Resident 48's toilet use documented within the MDS indicated that she required extensive assistance. A review of a document titled (Resident 48) monthly nursing home visit, dated 05/01/2023, indicated that Medical Director (MD) had seen the Resident during his nursing home visit to this facility. The note indicated that Resident 48 was stable on current treatment plan and had no new skin tears or wounds. A review of a radiology (medical imaging) results report dated 05/17/2023, indicated, The sacrum (bony structure at base of spine, connected to the pelvis that strengthens and stabilizes the pelvis) and coccyx are osteoporotic (A condition in which bones become weak and brittle) . Slight disruption of the posterior (near the back) soft tissues. The document indicated it was faxed to the nurse practitioner dated 05/17/2023. A review of a document titled, Change in Condition Assessment/SBAR, dated 05/17/2023 at 8:32 AM, indicated, Resident seen by (WD) for initial wound consultation today . Wound has changed from a stage 3 to a stage 4 . A review of a document titled, Braden Scale for Predicting Pressure Sore Risk Original, dated 05/18/2023, indicated Resident 48 had a Braden Scale (a scale that predicts risk for pressure ulcers), with total of 11 out of 23 (a lower score that indicated a higher risk for pressure ulcer development). The document indicated that Resident 48 had a very limited ability to respond meaningfully to pressure-related discomfort, and her skin was often moist, which required the bed linen to be changed at least once a shift. According to the document, Resident 48 had a very limited mobility range, which made her unable to significantly change her position frequently or independently. The friction and shear section indicated that Resident 48 had a problem and required moderate to maximum assistance in moving. A review of a document titled, Documentation Survey Report v2, between the dates of March 2023 and June 2023, indicated Resident 48 was incontinent of bowel and bladder often and required limited to extensive assistance to total dependence while performing bed mobility. A review of a nursing progress note dated 05/18/2023 at 12:17 PM, indicated WD assessed Resident 48's wound, and staged it as an unstageable pressure injury (tissue loss in which the extent of the tissue damage cannot be confirmed) to the coccyx. According to the progress note, the pressure ulcer measured 2cm x 1.5 cm, and WD performed a muscle debridement (removal of dead or infected skin tissue to help a wound heal) and staged the wound as a stage 4 pressure ulcer. Resident 48 was on a LALM (low air loss mattress, designed to let air out slowly to help keep the skin dry). Staff was to check brief and reposition/offload points of pressure at least every 2 hours and as resident will tolerate. A review of a weekly progress note dated 05/21/2023 at 12:20 AM, indicated, No new changes noted. No new skin issues noted this week . During a concurrent observation and interview on 06/20/2023 at 12:20 PM with Resident 48, she stated I have diarrhea today, they take their sweet time to change me. Resident 48 further stated she had a wound on her tailbone for approximately 3 months and wanted to be changed more frequently. Resident 48 appeared upset and pointed where her wound was located, pointing to her coccyx area. She stated she feared the wound getting worse and having feces seep into the wound and explained that made her feel very upset as she was not changed or cared for enough. During a concurrent interview and electronic record review on 06/22/23 at 11:30 AM, with the Director of Nursing (DON), she confirmed significant weight loss was considered a change of condition (COC) and the physician, responsible party, DON and ADON should be notified. The DON confirmed the following severe weight loss for Resident 48: On 02/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], On 02/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 01/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 08/20/23, 168.2]. The DON was not able to confirm a change of condition assessment was completed or the physician was notified of Resident 48 severe weight loss in February 2023. The DON confirmed the physician should be notified of a significant weight change the same day the weights were taken. During an interview on 06/23/2023 at 9:19 AM with CNA G, she stated the treatment nurse performs wound care on Resident 48. CNA G stated if the dressing on her coccyx was soiled by feces or urine, they would alert the treatment nurse so that they can come to change it, explaining that she will clean around the best she can. CNA G stated that Resident 48 could use the call light and informed staff that she needed to be changed, and staff would check on her every two hours, and further stated, She knows when she needs to be changed. She won't let her brief stay soiled or wet. During an interview on 06/23/2023 at 9:34 AM with CNA H, she stated Resident 48 would use call light to inform staff if she needed her brief changed. CNA H stated Resident 48 would inform the staff if she wished to be repositioned within the two hours, otherwise she was repositioned every two hours. During an interview on 06/23/2023 at 9:46 AM with LVN 2, she stated Resident 48 was repositioned and changed often. LVN 2 stated the pressure ulcer was unavoidable as Resident 48 was alert and informed staff of when she wanted to be changed. It was probably going to happen anyway with her condition. During an interview on 06/23/2023 at 10:00 AM with Treatment Nurse LVN (Tx LVN), stated when she was made aware of Resident 48's pressure wound it was already an open area. Tx LVN stated when Resident 48 was soiled she won't let staff know, which was a factor for the pressure ulcer having been unavoidable. She stated that Resident 48 had improvements to her pressure ulcer, and it was healing. Tx LVN stated Resident 48 received showers properly and she does not refuse her showers. She further stated that she was not sure if the wound starting at a stage 3 pressure ulcer was warranted or not, as nursing and CNAs should have noticed redness and abrasion (an area damaged by scraping or wearing away). Tx LVN stated if the pressure injury was reported timely, it would not have reached the level of a stage four pressure ulcer. During an interview on 06/26/2023 at 11:15 AM, the DON stated the treatment nurse would ask if Resident 48 could feel if she was soiled and to put on call light for staff to assist, and Resident 48 responded with no she can't. DON stated the procedure for a new wound of any kind was to have the treatment nurse look at it and treat it to see if it was resolvable prior to it becoming an actual pressure wound. Per DON, in this instance, the treatment nurse worked on the wound for a while and was not making progress and then the wound doctor was called. She stated during the time that the treatment nurse was working with the wound, it continued to worsen and there was not improvement. DON stated it was not a requirement to have the wound doctor look at the wound, I give her the freedom, if she isn't seeing progress then we can have the wound doctor. She stated the wound was not bad and it would be a matter of judgement that it worsened and timing of when the wound doctor came. DON stated usually if there are two weeks of no improvement with wounds, then it was escalated up to the wound doctor. She stated that this could have been a lack on the part of nursing and CNAs, as they should have done skin assessments and observed during showers. DON confirmed that Resident 48 did have diarrhea occasionally, a couple of times a week. She stated during IDT (interdisciplinary team) meetings, it was briefly discussed that the current wound care was appropriate and that the wound doctor did not need to be called. DON confirmed that there was not a policy talking towards when to reach out to a wound doctor, it is just nursing judgement. She stated that Resident 48 was on a LALM and provided the manufacturer's user manual for the Domus 4. A review of the user manual for Domus 4 (an LALM) dated 2018, indicated, This product is intended to help and reduce the incidence of pressure ulcers while optimizing patient comfort. It also provides following purposes: To help and reduce the incidence of pressure ulcers while optimizing patient comfort. For long-term home care of patients suffering from pressure ulcers. For pain management as prescribed by a physician.

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document and Policy and Procedure review, the facility failed to ensure acceptable parameters of nutritional status were maintained for one of 21 sampled residents (Resident 48) when: 1. A Change of Condition (COC) assessment was not completed, and the Physician was not notified of Resident 48's severe weight loss of 12.8 pounds (lbs.), 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 2/7/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23, 2. Weekly weights were not completed as ordered on 1/26/23 for Resident 48, and 3. Interventions to mitigate the severe weight loss of 12.8 pound (lbs.), 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 2/7/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23 for Residents 48 were not implemented in a timely manner. As a result of these failures, Resident 48's compromised nutritional status was not monitored and addressed timely which could lead to further medical complications including but not limited to skin breakdown. Findings: A professional reference review of American Academy of Family Physicians Journal titled, Unintentional Weight Loss in Older Adults, dated 2014 showed, Unintentional weight loss (i.e., more than a 5% reduction in body weight within six to 12 months) occurs in 15% to 20% of older adults and is associated with increased morbidity and mortality. In this population, unintentional weight loss can lead to functional decline in activities of daily living, increased in-hospital morbidity, increased risk of hip fracture in women, and increased overall mortality. Further, cachexia (loss of muscle mass with or without loss of fat) has been associated with negative effects such as increased infections, pressure ulcers, and failure to respond to medical treatments . https://www.aafp.org/afp/2014/0501/p718.html - afp20140501p718-b1. 1. A review of the facility P&P titled Acute Condition Changes - Clinical Protocol revised 3/2018 showed in part, 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay .2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician . Medical record review for Resident 48 was initiated on 6/22/23. Resident 48 was admitted to the facility on [DATE], with diagnoses including acute bronchitis (airways of the lungs swell and produce mucus in the lungs), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), and major depressive disorder (a mental condition characterized by a persistently depressed mood). Review of Resident 48's History and Physical Examination completed and signed by the Medical Director on 7/14/22, showed Resident 48's weight was 164 lbs., and rehabilitation potential was poor. Review of the facility document titled Order Summary Report for Resident 48 signed and dated by the Nurse Practitioner (NP) on 1/20/23, showed the following was ordered on 10/5/22, Regular Diet dysphagia (difficulty swallowing) advanced texture, thin consistency, on 7/26/22 food snack two times a day for supplement was ordered. Review of the facility document titled Order Summary Report for Resident 48 signed and dated by the NP on 3/6/23, showed the following was ordered on 1/26/23, Health shake (nutritional supplement) one time a day for supplement with breakfast. Review of the facility document titled Weights and Vitals Summary from 1/6/23 to 2/7/23 showed the following weights and comparison for Resident 48: *On 1/6/23 = 166 lbs., *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. Review of Resident 48's Quarterly Minimum Data Set (MDS, a standardized resident assessment) dated 1/21/23, showed under Section C, a BIMS (brief interview of mental status) score of 12 which indicated Resident 48 had moderate cognitive impairment, Section K of the MDS indicated Resident 48 weighed 166 lbs. and height was 62 inches, Resident 48 had not experienced a 5% or more weight loss in the past month or 10% or more weight loss in the past six months. Review of Resident 48's Quarterly MDS dated [DATE], showed under Section C, a BIMS score of 11 which indicated Resident 48 had moderate cognitive impairment, Section K of the MDS indicated Resident 48 weighed 154 lbs. and height was 62 inches, Resident 48 had experienced a 5% or more weight loss in the past month or 10% or more weight loss in the past six months, and was not on a physician-prescribed weight-loss regimen. Review of the Physician progress notes dated 2/1/23 electronically signed and dated by the medical director on 2/6/23 showed, Chief complaint: Monthly. Subjective: General: .no loss of appetite. Plan: continue to assess of change in condition, provide assistance as needed, follow up monthly and prn (as needed). Resident 48's body weight or oral intake was not mentioned in the monthly progress note. Review of the Physician progress notes dated 3/1/23 electronically signed and dated by the medical director on 3/9/23 showed, Chief complaint: Monthly. Subjective- General: no loss of appetite. Plan: continue to assess of change in condition, provide assistance as needed, follow up monthly and prn. Stable on current treatment plan at this time. Resident 48's body weight or oral intake was not mentioned in the monthly progress note. On 6/22/23 at 9:46 am, a review of Resident 48's electronic medical record and concurrent interview was conducted with Registered Nurse (RN) 1. When asked to explain the facility's process of significant weight changes, RN 1 stated nursing checked the weights in the computer, or the Restorative Nurse's Assistant (RNA) would let nursing know about a significant weight change. RN 1 stated RNA charting would also mention significant weight changes in the RNA progress notes. The RN 1 stated a change of condition (COC) assessment would be completed for significant weight changes. Nursing was responsible to notify the physician, the resident's responsible party, the Registered Dietitian (RD) and the Director of Nursing (DON) of the significant weight change. The IDT (interdisciplinary team-team members from different disciplines working collaboratively with a common purpose to set goals) would meet to discuss the plan of action for significant weight changes. RN 1 confirmed Resident 48 experienced the following severe weight loss: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. RN 1 added if a resident experienced a significant weight change the RNA would reweigh the resident. RN 1 confirmed Resident 48 was reweighed on 2/7/23 and had lost an additional 2.2 lbs. in two days. RN 1 stated a COC assessment was completed on 1/31/23 for Resident 48 due to new onset of confusion, lethargy and poor PO (by mouth) intake. RN 1 confirmed a COC was not completed and the physician was not notified of Resident 48's severe weight of 12.8 lbs., 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 27/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23. When asked what the acceptable time frame to notify the physician of a COC was, RN 1 stated the physician should be notified within 24 hours of the COC. On 6/22/23 at 11:00 AM, an interview and concurrent electronic record review for Resident 48 was conducted with the Assistant Director of Nursing (ADON). The ADON stated significant weight loss was considered a change in condition and the physician should be notified. The ADON confirmed Resident 48 experienced the following severe weight loss: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. The ADON was asked to show documentation the physician was notified of Resident 48's severe weight loss in February 2023. The ADON reviewed the physician progress notes dated 2/1/23 and 3/1/23 and confirmed Resident 48's severe weight loss was not mentioned. On 6/22/23 at 11:30 AM, an interview and concurrent electronic record review for Resident 48 was conducted with the DON. The DON confirmed significant weight loss was considered a COC and the physician, responsible party, DON and ADON should be notified. The DON confirmed the following severe weight loss for Resident 48: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. The DON was not able to confirm a COC assessment was completed or the physician was notified of Resident 48's severe weight loss in February 2023. The DON confirmed the physician should be notified of a significant weight change the same day the weights were taken. Cross reference to F580. 2. Review of the facility Policy and Procedure titled Weight Assessment and Intervention revised March 2022 showed, Weight Assessment- 2. Weights are recorded in each unit's weight record chart and in the individual's medical record. Review of the facility document for Resident 48 titled, Order Recap Report dated 1/26/23 showed on 1/26/23 the Nurse Practioner (NP) ordered weekly weights for four weeks to begin 1/31/23 then monthly. On 6/22/23 at 9:46 am, a review of Resident 48's electronic medical record and concurrent interview was conducted with RN 1. RN 1 confirmed an order for weekly weights for four weeks was written on 1/26/23, to be implemented on 1/31/23. RN 1 confirmed weekly weights were not completed for Resident 48 per the physician's order. On 6/22/23 at 10:29 AM an interview was conducted with RNA. RNA stated nursing was responsible to notify the RNA of weekly weight orders. RNA checked the weight binder for an order for weekly weights for Resident 48. RNA was not able to confirm she received an order from nursing to weigh Resident 48 weekly on 1/31/23. RNA stated communication between nursing and the RNA regarding weekly weight orders had been an ongoing problem. RNA stated any resident who lost five pounds, or more was automatically reweighed. RNA confirmed Resident 48 had lost more than five pounds on 2/2/23 and was reweighed on 2/7/23 but was not weighed again until March 6, 2023. On 6/22/23 at 11:30 AM an interview was conducted with the DON. DON confirmed Resident 48 had an order for weekly weights to begin on 1/31/23. The DON confirmed weekly weights had not been completed for Resident 48 as ordered. 3. Review of the facility Policy and Procedure titled Weight Assessment and Intervention revised March 2022 showed, Weight Assessment- 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria .a. one month - 5% weight loss is significant; greater than 5% is severe. b. three months - 7.5% weight loss is significant, greater than 7.5% is severe. c. six months- 10% weight loss is significant; greater than 10% is severe. Evaluation- 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. Review of the facility document for Resident 48 titled, Order Recap Report dated 3/01/23- 6/30/23 showed on 3/17/23 the medical director ordered 7.5 mg (milligram) of mirtazapine (anti-depressant) AEB (as evidenced by) loss of appetite related to major depressive disorder. A review of Resident 48's electronic medical record was initiated on 6/22/23 at 9:15 AM. The facility document titled RD- Nutrition Note completed and signed by RD on 2/6/23 showed in part, -Resident 48's weight was 153.2 lbs. on 2/5/23. Resident 48's weight history showed, 1/6/23 weight: 166 lbs., 12/3/22 weight: 168.8 lbs., 11/5/22 weight: 171.4 lbs.; 7.8 % 13 lbs. significant weight loss in 30 days, 10.6 % 18.2 lbs. significant weight loss in 90 days. -Diet order: Regular diet, dysphagia advanced texture, thin consistency -PO (by mouth) intake: mostly less than 50% for 14 meals, refused six meals. -Supplements: Health Shake with breakfast - intake approximately 50% for four days. -Fluids 120-480 ml/meal for seven days -Weekly weights (end date 2/28/23) -Resident is [AGE] year-old female who presents with significant weight loss in one and three months. Current PO intake is poor, does not appear adequate to meet ENN (estimated nutrition needs). Noted COC 1/31/23 for lethargy, new onset confusion .spoke with resident who reports poor appetite and having no interest in food .Resident was unaware of recent weight loss, RD encouraged adequate intake of meals, fluids, oral nutritional supplements to help prevent further weight loss May consider recommending appetite stimulant if no improvement in PO intake Monitor through IDT weight meeting PRN (as needed). Monitor PO intake, weight, skin integrity, labs as available. RD will continue to monitor per facility protocol and remain available. Review of the facility document titled IDT Review completed and signed by the RD on 2/9/23 showed in part, -2/7/23 weight 151 lbs., significant weight loss 15 lbs., 9% in 30 days, 20.4 lbs., 11.9% in 90 days. -PO intake mostly less than 50% for 14 days, refused six meals. -Supplements: Health Shake with breakfast - intake approximately 50% for seven days. --Current PO intake is poor .Noted weight loss 2.2 lbs. in two days (2/5-2/7). -Order for weekly weights for four weeks (end date 2/28/23) -Consider appetite stimulant if medically appropriate, continue to monitor weight trends. Review of the facility document titled RD- Nutrition Note completed and signed by the facility RD on 3/16/23 showed in part, -Resident 48 weighed 154.2 on 3/6/23, 153.2 on 2/5/23, 166 on 1/6/23, significant weight loss in 90 days, -14.6 lbs., 8.6% -Intake was variable 25-100% -Regular diet, Health Shake w/ Breakfast, -Skin intact, weight stable for one month, -Rec MVI (multivitamin) with minerals Review of the facility document titled IDT weight meeting completed and signed by the facility RD on 3/16/23 showed in part, -weights per RD note 3/16/23. -Recommend prostat (protein supplement) 30 ml (milliliter) every day for 30 days, -MVI with minerals. -Continue monthly weights. Review of the plan of care initiated on 2/6/23 for Resident 48 showed in part: -Resident 48 presents with significant weight loss: -7.8% (13 lbs.) since 1/6/23, -10.6% (18.2 lbs.) since 11/2/22. -Poor appetite -interventions- weekly weights (end date 2/28/23) -Recommend send extra juice, and ice cream. Consider appetite stimulant if medically appropriate. Monitor through IDT weight meeting PRN. Review of the facility document titled Nutritional Recommendations by Registered Dietitian dated 2/9/23 showed, the RD recommended to consider appetite stimulant if medically appropriate. On 6/22/23 at 11:00 AM, an interview was conducted with the ADON. The ADON stated if a resident experienced a significant weight change, the IDT would hold a meeting to discuss the significant weight change. The ADON confirmed Resident 48 experienced severe weight loss of 12.8 lbs., 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 27/23, and 17.2 lbs., and 10.2% between 8/20/22 and 2/7/23. The ADON stated the RD was aware of Resident 48's severe weight loss. On 6/22/23 at 3:00 PM an interview and concurrent electronic medical record review was conducted with the Lead RD. The Lead RD stated she was responsible to oversee facility RDs but did not evaluate facility RDs. The Lead RD stated the facility's previous RD's last day was 6/14/23. The Lead RD was asked to explain the process for RD recommendations. The Lead RD stated the RD entered resident recommendations electronically on the facility document titled Nutritional Recommendations by Registered Dietitian form each visit and emailed a copy to the DON, ADON and DSS. The goal to complete the RD recommendations was five days, maybe seven days maximum depending on the physician. The Lead RD was asked if the facility RD should follow up on RD recommendations that were not completed. The Lead RD stated the facility RD should follow up on RD recommendations that were not completed depending on the situation. The Lead RD stated the facility RD should speak with the Certified Dietary Manager (CDM) or DON to investigate why the RD recommendations were not completed. The Lead RD confirmed the facility RD recommended an appetite stimulant on 2/9/23 but the order for an appetite stimulant was not received until 3/17/23. The Lead RD was asked what the facility process was if a resident experienced a severe weight loss. The Lead RD stated the RD would assess the resident and recommend weekly weights as indicated. The Lead RD further stated a resident with a severe weight loss should be monitored according to the resident's situation and the RD's clinical judgement. The Lead RD added the facility RD should document the plan how often the resident would be monitored. The Lead RD confirmed the facility RD assessed Resident 48 on 2/6/23 but did not assess Resident 48 again until 3/16/23. The Lead RD was asked why the RD did not continue to monitor Resident 48 after the IDT discussed her severe weight loss on 2/9/23. The Lead RD stated she did not know why and did not want to speak for the facility RD. On 6/22/23 at 3:48 PM an interview was conducted with the ADON. The RD recommendations from 2/9/23 were reviewed with the ADON. The ADON kept a copy of the RD recommendations in a binder, and he stated he notified the physician of the RD recommendations. The ADON confirmed on 2/9/23 the RD recommended for an appetite stimulant for Resident 48. The ADON stated when the RD recommendations were completed, he wrote a check mark next to the RD recommendation. The ADON confirmed the RD recommendation for Resident 48 on 2/9/23 did not have a check mark meaning it was not completed. When asked why the recommendation for an appetite stimulant had not been ordered for Resident 48, the ADON stated he could not remember why the RD recommendation was not completed. The ADON confirmed there was no documentation the NP or physician were notified of the RD recommendation for an appetite stimulant. The ADON confirmed an order was received from the physician on 3/17/23 for an anti-depressant which was often used as an appetite stimulant. When asked what the expected time frame to complete RD recommendations was, the ADON stated the RD recommendations should be completed as quickly as possible. On 6/23/23 at 9:07 AM, an interview was conducted with Resident 48. Resident 48 was alert and able to answer questions. She stated the facility told her she had lost weight. Resident 48 stated she liked ice cream. Resident 48 was asked if she received snacks between meals, Resident 48 stated she only received snacks if she asked for them. Resident 48 complained she was tired all the time and was in constant pain. Resident 48 also stated she often had loose stools and had a sore on her tailbone. On 6/23/23 at 9:37 AM, an interview was conducted with the DON. The DON was asked who was responsible for the IDT weight meetings. The DON stated nobody was responsible or in charge of the IDT weight meetings. The DON stated the RD was responsible to determine what residents would be discussed in the IDT weight meeting. The DON was asked how long a resident with a severe weight loss and poor PO intake was monitored in the IDT meeting. The DON stated residents with significant weight loss were discussed until they were no longer a concern. The DON confirmed Resident 48 was discussed in the IDT meeting on 2/9/23 and not again until 3/16/23. On 6/23/23 at 11:55 AM an interview was conducted with the medical director. When asked how long a resident with severe weight loss and poor PO intake should be discussed with the IDT, the medical director confirmed a resident with severe weight loss and poor PO intake should be discussed with the IDT until the resident is stable.

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide 1 of 6 Residents (Resident 150) the right to be treated with dignity and respect when his clothes were visibly soiled. This failure led to the lack of self-esteem, frustration, and loss of dignity for Resident 150. Findings: During an observation and interview on 6/20/23 at 11:29 AM, Resident 150 was visibly agitated and expressing vocalizations of frustration, indicating it was due to a lack of clean clothing. Resident wearing visibly soiled white shirt, visibly soiled black sweatpants, and socks with shoes on. Resident able to verbalize he was waiting a long time for staff to help him, and then continued to vocalize agitation. During an observation and interview on 6/21/23 8:47 at AM, Resident 150 did state he wanted to buy more clothes to wear. Gestured to visibly soiled black shirt and visibly soiled black sweatpants and said yeah when asked if he wanted clean clothes to wear. Resident 150 stated he would go to Walmart to buy more clothes for himself, but the facility can't take him. During an observation and interview on 6/22/23 at 8:41 AM, Resident 150 was awake in bed, watching television. Resident 150 agreed to an interview. Wearing a clean black shirt, grey sweatpants, that appeared to be moderately wet in the groin area, and socks with black shoes. Resident 150's skin and face appeared clean. Resident 150 had mild to moderate hearing impairment but could hear when spoken to loudly. His speech was moderately slurred. Resident 150's speech was understood with minimal clarification. He nodded and gestured appropriately. Resident able to verbalize that he liked wearing clean clothes. He indicated his current clothes were hand me downs from the facility. He stated he lets staff take his soiled clothes to launder them, but I don't get them back, I got different ones when clothing returned. When asked his preference, he stated he'd prefer new clothes over borrowed hand-me-downs. Resident 150 was able to show his closet; no other clothing visible besides what he was wearing. His hat, belt, cell phone, and shoes were his own, and present in the room. During a review of the facility's policy titled Resident Rights, dated December 2016, it indicated that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the right to: a dignified existence, [and] to be treated with respect, kindness, and dignity . During review of facility's policy titled Dignity, it indicates that each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. During an interview on 6/21/23 at 3:53 PM with Social Services Director (SSD), when asked what to do if a resident asked for new clothes or more clothes, SSD stated if it was the first time, she would call family to bring in any clothes. If family not able, she would tell the administrator, who might purchase clothes. If the resident had no personal funds or money, SSD would go to administrator and come up with plan to get the resident new clothes. During an Interview on 6/22/23 at 8:55 AM, the Laundry Manager (LM) was asked what the facility process was for a resident who had no clothing and wanted new clothing. LM stated they can go into donation closet, bring residents a couple sets of clothing. CNA's (Certified Nurse's Assistants) could access the donation closet at all times of day, but should tell LM, who will tag that clothing with name, for the resident to keep. During an Interview on 6/22/23 at 9:25 AM, the Administrator (ADMIN) was asked of the process to obtain new clothing or personal items for a resident who arrived with no money, no family, and no other resources, and was expressing desire to get new clothing. ADMIN stated they would immediately work out a plan with Social Services. ADMIN stated she would talk with the resident, and use Amazon, so resident could pick exactly what they wanted, and offer choices. Would use corporate company credit card, under Resident Expenses.

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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Based on interview, medical record review, and facility P&P review, the facility failed to ensure the physician was informed of a change of condition for one of 21 sampled residents (Resident 48). This failure had the potential for Resident 48 to have a delay in care and treatment. Findings: A review of the facility P&P titled Acute Condition Changes - Clinical Protocol revised 3/2018 showed in part, 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay .2. In addition, the nurse shall assess and document/report the following baseline information: a. Vital signs; .7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician . Review of the facility document titled Weights and Vitals Summary from 1/6/23 to 2/7/23 showed the following weights and comparison for Resident 48: *On 1/6/23 = 166 lbs., *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. On 6/22/23 at 9:46 am, an interview and concurrent review of Resident 48's electronic medical record was conducted with RN 1. When asked to explain the process of significant weight changes, RN 1 stated nursing checked the weights in the computer, or the RNA would let nursing know about a significant weight change. RN 1 stated RNA charting would also mention significant weight changes in the RNA progress notes. The RN 1 stated a change of condition (COC) assessment would be completed for significant weight changes. Nursing was responsible to notify the physician, the resident's responsible party, the Registered Dietitian (RD) and the DON of the significant weight change. The IDT (interdisciplinary team-team members from different disciplines working collaboratively with a common purpose to set goals) would meet to discuss the plan of action for significant weight changes. RN 1 confirmed Resident 48 experienced the following severe weight loss: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. RN 1 added if a resident experienced a significant weight change the RNA would reweigh the resident. RN 1 confirmed Resident 48 was reweighed on 2/7/23 and had lost an additional 2.2 lbs. in two days. RN 1 stated a COC assessment was completed on 1/31/23 for Resident 48 due to new onset of confusion, lethargy and poor PO (by mouth) intake. RN 1 confirmed a COC was not completed and the physician was not notified of Resident 48's severe weight of 12.8 lbs., 7.7 % between 1/6/23 and 2/5/23, 15 lbs., 9% between 1/6/23 and 27/23, and 17.2 lbs., 10.2% between 8/20/22 and 2/7/23. When asked what the acceptable time frame to notify the physician of a COC was, RN 1 stated the physician should be notified within 24 hours of the COC. On 6/22/23 at 11:00 AM, an interview and concurrent electronic record review for Resident 48 was conducted with the ADON. The ADON stated significant weight loss was considered a change in condition and the physician should be notified. The ADON confirmed Resident 48 experienced the following severe weight loss: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. The ADON was asked to show documentation the physician was notified of Resident 48's severe weight loss in February 2023. The ADON reviewed the physician progress notes dated 2/1/23 and 3/1/23 and confirmed Resident 48's severe weight loss was not addressed by Resident 48's physician. On 6/22/23 at 11:30 AM, an interview and concurrent electronic record review for Resident 48 was conducted with the DON. The DON confirmed significant weight loss was considered a COC and the physician, responsible party, DON and ADON should be notified. The DON confirmed the following severe weight loss for Resident 48: *On 2/5/23 = 153.2 lbs., -12.8 lbs., a 7.7% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -15.6 lbs., a 9.2% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.6 lbs., a 10.3% severe weight loss in five months [comparison weight on 9/1/23, 170.8 lbs.], *On 2/7/23 = 151 lbs., -15 lbs., a 9% severe weight loss in one month [comparison weight on 1/6/23, 166 lbs.]; -17.8 lbs., a 10.5% severe weight loss in two months [comparison weight on 12/3/22, 168.8 lbs.]; -17.2 lbs., a 10.2.% severe weight loss in five and a half months [comparison weight on 8/20/23, 168.2 lbs.]. The DON was not able to confirm a COC assessment was completed or the physician was notified of Resident 48 severe weight loss in February 2023. The DON confirmed the physician should be notified of a significant weight change the same day the weights were taken.

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide an accurate and complete assessment for one of six sampled residents (Resident 23) when an assessment dated [DATE] indicated no skin conditions were present, although Resident 23 had known open areas on both legs. These failures had the potential for staff to not be fully informed of her health status, to determine the need for further assessment and interventions that could result in delays in care and decline in resident's condition. Findings: The facility policy and procedure titled, Comprehensive Assessments, revised 3/2022 indicated that comprehensive assessments are conducted to assist in developing person-centered care plans and in accordance with criteria and timeframes established in the Resident Assessment Instrument (RAI) manual. A significant error differs from a significant change because it reflects incorrect coding of the MDS and not an actual significant change in the resident's health status. During a review of a record, Resident 23 was admitted to the facility on [DATE] with diagnoses that included Guillain-Barre Syndrome, (a rare disorder in which your body's immune system attacks nerves, eventually paralyzing the whole body), high blood pressure, and dependence on wheelchair. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 23 dated 4/14/23, indicated that Resident 23 had a slight cognitive deficit, with a brief interview for mental status (BIMS) score of 12, but was her own responsible party, and required extensive assistance with transfers, toileting, and bathing. The MDS assessment for skin problems listed none for any altered skin integrity, no rashes, no red areas or open areas. The MDS did not document any refusals of care. A review of the physician's orders for Resident 23 dated 6/23/23 indicated ammonium lactate cream 12% was ordered to apply cream to bilateral lower extremities topically two times daily for dry, scaly skin with a start date of 8/8/22. During a concurrent observation and interview on 6/23/23 at 2:21pm, Resident 23 with noted open areas to right lower shin, right medial foot, red scattered areas on bilateral legs. A black area noted to the mid shin on right lower leg. Observed multiple red areas, yellow slough to right lower leg, right medial foot, necrotic looking area to mid lower shin with a red area around, scab type areas. Bilateral lower legs also noted with a petechiae small red type dots from the knees down to both ankles. Resident 23 stated, Yes, you can look at my legs, but please do not touch them, they hurt so bad to touch them. My legs are really sore. During an interview on 6/23/23 at 2:30 PM, Licensed Vocational Nurse (LVN) 2 stated, The treatment nurse does not apply the cream for Resident 23 ordered, we do, the nurses on the med cart. [Resident 23] refuses most days; the cream is ordered two times daily for bilateral legs. She refuses because it hurts her too bad, but we do ask if she will let us apply it. Today, I was able to apply just a little bit. During an interview on 6/23/23 at 3:01 PM, with the Director of Nursing (DON), with the Assisted Director of Nursing present (ADON), DON stated, I am aware of Resident 23's legs, but she refuses a lot. Those areas have been there a long time. I saw the open area on Tuesday during Resident 23's shower, with two other staff members present. Certified Nursing Assistant (CNA) G and LVN 3. I sprayed Lidocaine on both of her legs first to help with the pain, and then I pulled a few scab areas off. No, it is not a wound order, just some type of skin condition.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on Interview and Record Review, the facility failed to ensure a baseline care plan was developed and implemented for 1 of 20 sampled residents (Resident 150) within 48 hours of admission, which placed the resident at risk for their immediate needs not being determined nor met. Findings: During an observation and interview on 06/20/23 11:29 AM, Resident 150 was visibly agitated and expressing vocalizations of frustration, indicating it was due to a lack of clean clothing. Resident wearing visibly soiled white shirt, visibly soiled black sweatpants, and socks with shoes on. Resident able to verbalize he was waiting a long time for staff to help him, and then continued to vocalize agitation. During a review of Resident 150's admission record dated 6/6/23, it indicated Resident 150 was admitted to facility on 6/6/23 with diagnoses of muscle weakness, dysphagia, and cognitive communication deficits. During a review of the facility's policy titled Care Plans - Baseline, dated March 2022, it indicated a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. During a review of minimum data set (Resident Assessment, admission Assessment) dated 6/13/23, it indicated Resident was cognitively intact, had hearing impairment, unclear speech clarity, and only sometimes understands staff or was able to be understood. Vision listed as adequate, and a BIMS score recorded as 12. During a review of Resident 150's 48-hour baseline care plan, it indicated it was dated 6/9/23, more than 48 hours after the admission date of 6/6/23. This baseline care plan indicated that resident had difficulty communicating with staff and had vision and hearing impairment. It also indicated Resident would require 1-person physical assist with Activities of Daily Living (ADL's) including dressing, toilet use, personal hygiene, and bathing, and mobility. It indicated Resident was alert, with cognitive impairment. A review of admission Face sheet on 6/22/23 11:30 AM for Resident 150, indicated Resident was recorded as being their own Representative and Responsible Party. During a concurrent record review and interview on 06/22/23 10:09 AM with MDS RN, she verbally confirmed that Resident 150's baseline care plan was completed and submitted on 6/9/23, more than 48 hours after admission, and locked into system on 6/12/23. During an interview on 06/22/23 9:51 AM with Speech Therapist (ST/OT), she verbally summarized Resident 150's interventions for communication, including slow manner, speaking louder, waiting for response. Stated Resident 150 has improved communication since admission, which has in turn improved his overall mood. ST/OT stated upon admission, he would become frustrated and angry when trying to communicate with staff. ST/OT stated therapy notes and suggestions should be appear in the electronic medical record for aids/staff to see, to also do same interventions. During an interview on 06/22/23 10:05 AM with LVN 1. Asked how to see most recent Speech Therapy suggestions/notes for staff. She quickly pulls up therapy in the electronic medical record, and showed the therapy profile for a resident, with precautions, interventions, recent notes. LVN 1 stated she would review this area before working with any resident receiving therapies. She stated it served as a guide for other staff to use for that resident, and staff could access care plans and progress notes.

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 interview and record review, the facility failed to develop a comprehensive and person-centered Care Plan for one of three sampled residents (Resident 8) when there was nothing included for depression. This failure had the potential for Resident 8's needs to go unmet which could have negatively impacted their health and well-being. Findings: A review of Resident 8's clinical record showed they were admitted to the facility on [DATE] with diagnoses that included multiple sclerosis (a chronic disease of the central nervous system that caused muscle weakness), anxiety (nervousness), psychosis (loss of touch with reality), and schizoaffective disorder bipolar type (a mental health disorder that was marked by a combination of hallucinations or false beliefs and extreme highs and lows of mood). Medications ordered for Resident 8 included olanzapine for psychosis as evidenced by yelling that interfered with care, and clonazepam for anxiety as evidenced by verbalization of worries over health concerns. Review of Resident 8's Minimum Data Set (MDS---a standardized resident assessment) dated 4/1/23, showed a PHQ-9 (a health questionnaire that screened for depression) severity score of 9, which indicated possible mild depression. Record review of Resident 8's Care plan showed interventions for the problems of anxiety, psychosis, and insomnia (problems sleeping), but no Care Plan for a potential for depression. During a concurrent interview and record review, on 6/23/23, at 1:57 PM, the Social Services Director stated that if the PHQ-9 score was greater than three and there was no diagnosis of depression, they could have created a potential for depression Care Plan. During a concurrent interview and record review, on 6/23/23, at 2:15 PM, the Director of Nursing looked up Resident 8's MDS and Care Plan. There was no Care Plan for depression or for potential for depression created based on the PHQ-9 score of nine documented on the 4/1/23 MDS.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the nursing staff failed to identify and report a skin condition with open areas for one out of six sampled residents (Resident 23) to ensure services being provided meet Professional Standards of Care. This failure to meet Professional Standards of Care resulted in Resident 23 to refuse care related to discomfort of both lower legs, and the potential for an infection with a skin condition with open areas to both lower legs. Findings: During a review of a policy revised March 2018, titled Acute Changes-Clinical Protocol, for Assessment and Recognition indicated the nurse shall assess and document/report baseline information. Direct care staff including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example changes in skin color or skin condition). Review of the California Board of Registered Nursing website, California Business and Professions Code, Division 2, Chapter 6, Article 2, Section 2725(b)(2), indicated RNs should ensure the safety, protection of residents; administration of medications, and therapeutic agents, necessary to implement a treatment, disease prevention, ordered by and within the scope of the licensure of a physician. During a review of the record, Resident 23 was admitted to the facility on [DATE] with diagnoses that included Guillain-Barre Syndrome, (a rare disorder in which your body's immune system attacks nerves, eventually paralyzing the whole body), high blood pressure, and dependence on wheelchair. A review of the physician's orders for Resident 23 dated 6/23/23 indicated ammonium lactate cream 12% was ordered to apply cream to bilateral lower extremities topically two times daily for dry, scaly skin with a start date of 8/8/22. During a concurrent observation and interview on 6/23/23 at 2:21pm, Resident 23 with noted open areas to right lower shin, right medial foot, red scattered areas on bilateral legs. A black area noted to the mid shin on right lower leg. Observed multiple red areas, yellow slough to right lower leg, right medial foot, necrotic looking area to mid lower shin with a red area around, scab type areas. Bilateral lower legs also noted with a petechiae small red type dots from the knees down to both ankles. Resident 23 stated, Yes, you can look at my legs, but please do not touch them, they hurt so bad to touch them. My legs are really sore. During an interview on 6/23/23 at 2:30 PM, Licensed Vocational Nurse (LVN) 2 stated, The treatment nurse does not apply the cream for Resident 23 ordered, we do, the nurses on the med cart. Resident 23 refuses most days; the cream is ordered two times daily for bilateral legs. She refuses because it hurts her too bad, but we do ask if she will let us apply it. Today, I was able to apply just a little bit. During an interview on 6/23/23 at 3:01 PM, with the Director of Nursing (DON), with the Assisted Director of Nursing present (ADON), DON stated, I am aware of Resident 23's legs, but she refuses a lot. Those areas have been there a long time. I saw the open area on Tuesday during Resident 23's shower, with two other staff members present. Certified Nursing Assistant (CNA) G and LVN 3. I sprayed Lidocaine on both of her legs first to help with the pain, and then I pulled a few scab areas off. No, it is not a wound order, just some type of skin condition. During a phone interview with the Licensed Vocational Nurse, who is the treatment nurse, (LVN Tx) on 6/23/23 at 3:14 PM, while the DON was holding phone on speaker stated, I do not do a treatment for Resident 23. I have been a wound nurse here for one year and a half now. I have attempted to shower Resident 23, but she screamed a lot. I do remember two isolated incidents and she did not tolerate well, so I called her family member (FM). The most recent attempt was within the past two months, the staff told me to go out and look at her legs, she had an open area to her right shin. There was a piece of skin hanging in between a hair and I clipped the hair removing the skin with my scissors. The med nurses on the cart apply the cream to Resident 23, I do not. During the phone interview on 6/23/23 at 3:18 pm with LVN Tx and DON, both confirmed the Nurse Practitioner (NP) had not been updated with a new open area and an ongoing skin problem on bilateral legs to complete an evaluation and/or referral for a wound consult. During an interview on 6/26/23 at 11:00 AM, the NP at facility was interviewed about Resident 23's skin issues on both lower legs. NP stated he was unsure what the skin condition was and will look into it, may be autoimmune, may require some labs to determine, they may start as blisters, turn into scabs. NP confirmed that he was unaware of the skin issues and that the wound physician had not been in to see Resident 23 in 2 years. NP stated there should have been a consultation and a plan of care developed to treat the skin condition. During an interview on 6/23/23 at 3:20 PM, DON confirmed Resident 23 had not had a wound consult since June 2021, even with a skin condition undiagnosed. DON also confirmed she did not document the skin assessment in the shower on 6/19/23 but entered a late entry for 6/19/23 on 6/23/23 effective 6/21/23. During a record review on 6/23/23 at 3:38 pm, for Resident 23's medical chart, there were no skin assessments that listed a rash, any red areas, and listed skin dry and scaly. No progress notes or alert notes were documented to describe the bilateral leg skin red areas, yellow areas or any changes in skin. All skin assessments stated None for the last two months in the medical chart for skin problems. There were no updates to the NP, medical director or any wound consultant related to the skin condition on both lower legs, right foot by any nursing staff. During a review of Resident 23's medical chart a document dated 6/26/23 titled, Alert Note, indicated NP met with Resident 23 to assess bilateral Lower Extremities (LE). No new orders at this time, Referred to Dermatology for consultation. During a review of Resident 23's medical chart a document dated 6/28/23 titled, IDT, Interdisciplinary Team, a team of clinicians who provide care) indicated the following: IDT met to review skin condition of Resident 23 on her legs. This is not a new condition and has been seen in the past by the wound doctor with no resolution. Recently a new plan was designed to treat Resident 23's legs with Lidocaine spray prior to showers. This might tolerate some scrubbing to clean and clear the area. This has been mildly effective.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the necessary care and services and devices to maintain or improve hearing difficulty, for one of one resident reviewed for communication-sensory (Resident 3). This failure had the potential for Resident 3 to not effectively communicate and express her needs, which potentially negatively affected her well-being and quality of life. Findings: A review of a policy titled, Hearing Impaired Resident, Care of, with a revised date of February 2018, indicated, Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. A review of the facility's records indicated Resident 3 was admitted to the facility on [DATE] after a hospital stay, with an initial admission date of 11/26/2019. Resident 3 had diagnoses that included: generalized muscle weakness, vascular dementia, cognitive communication deficit (difficulty with thinking and how someone uses language), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), other schizoaffective disorders (mental health disorder where the individual can experience psychosis and mood symptoms), anxiety disorder, and unspecified hearing loss, bilaterally (both sides). A review of a document titled, Inventory of Personal Effects, dated on 01/17/2023, indicated Resident had 1 charger, hearing aids, on that date. A review of an activity participation note dated 04/20/2023 at 8:36 AM, indicated Resident 3, has a hearing . impairment and requires her . hearing aids to participate in group activities . A review of a social services progress note dated 06/05/2023 at 3:30 PM, indicated Resident 3's, hearing aids were brought to social services office and SSD (Social Services Director) was advised they are not working. RNA (Restorative Nurse Assistant) says they were fully charged but are not operational. SSD contacted . audiologist . she would do her best to fix them . and SSD mailed the hearing aids to the audiologist for repair. A review of a social services progress note dated 06/20/2023 at 7:24 AM, indicated, Social services provided a hearing amplifier (wearable device that uses a microphone to pick up nearby sounds) . for use until hearing aids are returned . she 'liked them' . During an interview on 06/20/2023 at 10:30 AM with CNA (Certified Nursing Assistant) M, she stated Resident 3 was hard of hearing and had been waiting on her hearing aids for awhile, maybe two weeks. During a concurrent observation and interview on 06/20/2023 at 10:35 AM with Resident 3, she stated she does not have her hearing aids and explained that made her not happy as she was admitted to the facility with her hearing aids and should have them by now. It was observed that Resident 3 had trouble hearing and had to be communicated with very loudly by staff and Resident 3 would not understand the entire conversation properly as she had difficulty hearing. During an interview on 06/23/2023 at 9:19 AM with CNA H, she stated Resident 3 received temporary hearing aids 2-3 days ago. She was unsure if Resident 3 had hearing aids between the time period of 06/05/2023 to the last 2-3 days. During an interview on 06/23/2023 at 11:41 AM with SSD, she stated around 06/05/2023 RNA had given her the hearing aids and she mailed them to the audiologist on 06/05/2023. She further stated an amplifier device was given to the resident earlier in the week until her hearing aids are repaired and Resident 3 really liked that. SSD confirmed that between the time period of 06/05/2023 to 06/19/2023, Resident 3 would have been extremely hard of hearing, but it was not brought to her attention of a difficulty in communication between staff and Resident 3 until 06/19/2023, which was when SSD gave Resident 3 an amplifier device. We've had the amplifiers for a while, and stated nobody had said the resident was having difficulty until that week. SSD stated, RNA/CNA/nursing staff should have communicated earlier that Resident 3 was having issues so it could have been fixed immediately, staff dropped the ball. She stated the issue was not communicated to anybody in a leadership role as they each know about amplifiers. We know she loves her hearing aids, they're important to her. SSD stated it would be beneficial for it to become a standard of practice to provide amplifiers immediately when a resident's hearing aids are taken to be repaired. During an interview on 06/26/2023 at 11:15 AM with the Director of Nursing (DON), she stated it should have been communicated from nursing staff to DON or SSD earlier. DON stated she would make it a standard of practice to have amplifiers given right away when a resident's hearing aids are taken to be repaired. She stated Resident 3 loves her hearing aids, and wears them daily, and if the facility has the ability to have the amplifiers, then they should give them to the resident's that would benefit from them.

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 observation, interview, and record review the facility failed to ensure two residents out of six sampled residents (Resident 302 and 303) were treated for pain in a timely manner by not identifying and reporting a new onset of pain. This failure resulted in altered mood, and the potential to cause a decline in health status and overall quality of life. Findings: 1- A review of a policy revised March 2018, titled Pain-Clinical Protocol, indicated the nursing staff will assess each individual for pain upon admission to the facility and when there is onset of new pain. The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated. The staff and physician will evaluate how pain is affecting mood, activities of daily living, sleep, quality of life, as well as how pain can be contributing to complications such as gait disturbances, social isolation, and falls. During a record review, Resident 302 was admitted to the facility on [DATE] for diagnoses that included fracture of left ankle, high blood pressure and other disorders of bone density. During a record review for Resident 302, the Minimum Data Set, (MDS, a resident assessment tool) had not been completed as of 6/23/23. During a concurrent observation and interview on 6/20/23 at 10:41AM, Resident 302 was moaning in pain and rubbing both eyes. Both periorbital, (the area around the eyes) areas were red and with noted edema. Resident 302 stated, They need to rinse this rag, I cannot keep it over my eyes all day. This is driving me crazy; it hurts all over my eyes. I don't think I have had my eye drops yet. Resident with visible restlessness and tearful. During an interview on 6/20/23 at 10:50 AM, the Director of Staff Development (DSD) confirmed Resident 302 was alert and oriented, able to verbalize needs, and a new admission to the facility. During an interview on 6/20/23 at 10:52 AM, DSD working on medication cart, stated, I have not given Resident 302's eye drops yet. Yes, they are ordered twice a day, but I have not got to her yet. During a review of Resident 302's medication orders, dated 6/22/23 indicated Refresh Plus Ophthalmic Solution was ordered to instill two drops in both eyes two times a day for dry eyes effective 6/19/23. During a review of Resident 302's medication orders, dated 6/22/23 indicated a new medication Maxitrol Ophthalmic Ointment (Neomycin-Polymy-Dexameth) 3.5-10000-0.1 IU, (a unit of measure), instill one dose in both eyes three times a day for eye orbit pruritis. During a review of Resident 302's medical chart, a document dated 6/21/23 5:03 PM titled, Alert Note, indicated MD, (Medical Director) met with Resident 302 to discuss itchiness around eyes. Ordered Maxitrol ointment to relieve itchiness three times a day. Resident 302 is excited about the new medication and relief of itchiness. 2- During a record review, Resident 303 was admitted to the facility on [DATE] with diagnoses that included cardiac disease with a recent heart valve replacement, diabetes, and kidney disease. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 303 dated 6/9/23, indicated that Resident 303 had a brief interview for mental status (BIMS) score of 14, no noted cognitive impairment and was her own responsible party. During an observation and interview at 10:49 AM, the Speech Therapist called the language line. Through the professional translator via cell phone, Resident 303 stated, My head hurts a lot, a 10. I want the white pill to make it stop. It has hurt a long time today, yes, a pain scale of 10 being the worst pain. I want water with my white pill to make it stop, pointing to forehead. During an interview on 6/20/23 at 10:55 AM, CNA J stated, I have never used the language line, I just get a CNA or any staff that speaks Spanish. I have been here since December 2022. I do not have the language line. I just try different things for the resident. I think she wants to get out of bed, I will get someone to help me. During an observation and interview at 11:10 AM, the Speech Therapist continued to hold the phone for translation. Through the professional translator Resident 303 stated, I do not want to get up, my head hurts. I just need a pillow behind me, but I do not want to get out of bed. During an interview at 11:15 AM, CNA J confirmed she was going to update DSD on the medication cart Resident 303 had a headache and was requesting something for pain. During an interview at 11:55 AM, DSD confirmed she gave Resident 303 medication for her headache and would follow up to make sure is is effective. During a record review for Resident 303, physician orders dated 6/22/23 indicated Resident 303 was ordered Tylenol Tablet 325 milligrams, (mg, a unit of measurement) two tablets by mouth as needed every four hours for mild pain. During an interview on 6/22/23 at 8:01 AM, the administrator confirmed Resident 302 was not treated for pain in a timely manner and agreed the MD should have been updated before 6/21/23 for the new medication ordered for severe eye irritation, pain and discomfort. The administrator also confirmed Resident 303 had a delay for pain management related to the communciation barrier and the CNA not updating the medication nurse Resident 303 had a headache.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 23's) medical care was supervised by a physician, when staff applied lidocaine (a topical pain reliever) to open areas on both legs without a physician's order. This failure resulted in Resident 23 not receiving a physician consultation of an ongoing skin problem, and not receiving timely and appropriate treatment and interventions. Findings: During a review of a policy revised March 2018, titled Acute Changes-Clinical Protocol, for Assessment and Recognition indicated the nurse shall assess and document/report baseline information. Direct care staff including nursing assistants will be trained in recognizing subtle but significant changes in the resident (for example changes in skin color or skin condition). Before contacting a physician, the nursing staff will collect pertinent details to report to the physician. The nursing staff will contact the physician based on the urgency of the situation. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. The physician will help identify and authorize appropriate treatments. The staff will monitor and document the resident's progress and responses to treatments, and the physician will help the staff monitor a resident with a change of condition until the problem or condition has resolved or stabilized. Review of the Nurse Practice Act for the State of California Section 2725 Subsection (B) (2) (https://leginfo.legislature.ca.gov/faces/codes_displayText.xhtml?lawCode=BPC&division=2.&title=&part=&chapter=6.&article=2.) revealed licensed nurses are not allowed to administer treatments without a physician's order. During a review of the record, Resident 23 was admitted to the facility on [DATE] with diagnoses that included Guillain-Barre Syndrome, (a rare disorder in which your body's immune system attacks nerves, eventually paralyzing the whole body), high blood pressure, and dependence on wheelchair. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 23 dated 4/14/23, indicated that Resident 23 had a slight cognitive deficit, with a brief interview for mental status (BIMS) score of 12, but was her own responsible party, and required extensive assistance with transfers, toileting, and bathing. The MDS for section M, assessment for skin problems listed none for any altered skin integrity, no rashes, no red areas, or open areas were documented. A review of the physician's orders for Resident 23 dated 6/23/23 indicated ammonium lactate cream 12% was ordered to apply cream to bilateral lower extremities topically two times daily for dry, scaly skin with a start date of 8/8/22. During a concurrent observation and interview on 6/23/23 at 2:21pm, Resident 23 with noted open areas to right lower shin, right medial foot, red scattered areas on bilateral legs. A black area noted to the mid shin on right lower leg. Observed multiple red areas, yellow slough to right lower leg, right medial foot, necrotic looking area to mid lower shin with a red area around, scab type areas. Bilateral lower legs also noted with a petechiae small red type dots from the knees down to both ankles. Resident 23 stated, Yes, you can look at my legs, but please do not touch them, they hurt so bad to touch them. My legs are really sore. During an interview on 6/23/23 at 3:01 PM, with the Director of Nursing (DON), with the Assisted Director of Nursing present (ADON), DON stated, I am aware of Resident 23's legs, but she refuses a lot. Those areas have been there a long time. I saw the open area on Tuesday, (Monday per bathing sheet) during Resident 23's shower, with two other staff members present. Certified Nursing Assistant (CNA) G and LVN 3. I sprayed Lidocaine on both of her legs first to help with the pain, and then I pulled a few scab areas off. No, it is not a wound order, just some type of skin condition. During the phone interview on 6/23/23 at 3:18 pm with Licensed Vocational Nurse, (LVN Tx) nurse and DON, both confirmed the Nurse Practitioner (NP) had not been updated with a new open area and an ongoing skin problem on bilateral legs to complete an evaluation and/or referral for a wound consult. During an interview on 6/23/23 at 3:20 PM, DON confirmed Resident 23 had not had a wound consult since June 2021, even with a skin condition undiagnosed. DON also confirmed she did not document the skin assessment in the shower on 6/19/23 but entered a late entry for 6/19/23 on 6/23/23, with an effective date of 6/21/23. During a review of Resident 23's physician's orders dated 6/23/23, a verbal order was documented as follows: Apply burn spray (lidocaine 2%) to bilateral lower extremities (BLE) before showers to allow proper cleansing of the legs. This order was obtained three days after DON stated she applied the lidocaine spray in the shower on 6/19/23, date of verbal order was 6/23/23. During an interview on 6/26/23 at 11:00 AM, the NP at facility was interviewed about Resident 23's skin issues on both lower legs. NP stated he was unsure what the skin condition was and will look into it, may be autoimmune, may require some labs to determine, they may start as blisters, turn into scabs. NP confirmed that he was unaware of the skin issues and that the wound physician had not been seen her in 2 years. NP stated there should have been a consultation and a plan of care developed to treat the skin condition. During a review of Resident 23's medical chart a document dated 6/26/23 titled, Alert Note, indicated NP met with Resident 23 to assess bilateral LE. No new orders at this time, Referred to Dermatology for consultation. During a review of Resident 23's medical chart a document dated 6/28/23 titled, IDT, Interdisciplinary Team, a team of clinicians who provide care) indicated the following: IDT met to review skin condition of Resident 23 on her legs. This is not a new condition and has been seen in the past by the wound doctor with no resolution. Recently a new plan was designed to treat Resident 23's legs with Lidocaine spray prior to showers. This might enable Resident 23 to tolerate some scrubbing to clean and clear the area. This has been mildly effective.

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 and record review, the facility failed to accommodate seven out of out of 20 residents (Residents 10, 20, 24, 35, 36, 64, and 82) with preferred food preferences when dietary staff did not update or serve the dietary preferences the residents requested or tried to obtain an alternate. This failure created the potential for a lack of the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss. Findings: During a review of a policy revised October 2017, titled Food and Nutrition Services, indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking in consideration the preferences of each resident. Food and Nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and is served at a safe and appetizing temperature. During a review of a record, Resident 10 was admitted to the facility on [DATE] with diagnoses that included diabetes, heart disease, and high blood pressure. During an interview on 6/21/23 at 8:01 AM, Resident 10 stated, Yesterday, I did not get the lettuce and tomato plate and it is listed on my meal ticket. I did not receive my half egg salad sandwich. They never offer a snack, they are slipping. I get a snack if I ask, but they do not offer. I get a snack, unless they tell you there are no snacks, nothing in the pantry. I wanted a peanut butter and jelly sandwich, it was not made because they are short staffed, on Fathers' day there were only two people working in the kitchen. During an interview on 06/23/23 11:05 am, Resident 10 showed hand written notes, menu not followed, preferences not provided, nurse wrote on ticket lettuce and tomato not on tray, circled by nurse Wednesday, 6/21/23 at lunch, did not bring or call the kitchen. Resident 10 stated, We never get snacks offered at bedtime, we have to ask. My roommates never get them either, I am a diabetic so I need one, but they could offer my roommates one too. During an interview on 6/20/23 at 11:30 AM, Resident 20 stated, The food sucks, there's not a lot of alternatives. The temperature varies but it is often cold. During an interview on 6/20/23 at 11:00 AM, Resident 24 stated, I do not like the food. They do not bring alternatives. The kitchen does not follow preferences. Preparation is bad. The cook seems bad. We get a lot of hot dogs and mashed potatoes. If you ask for fresh fruit, it is canned or an apple. During an interview on 6/20/23 at 9:50 AM, Resident 35 stated, Food is cold. It is cold to frozen most of the time. If you send it back, you can only get a cheese sandwich there are no options. During an interview on 6/20/23 at 1:00 PM, Resident 36 stated, The food is lousy. It is always cold. It is either under cooked or over cooked. Sometimes they send my preferences, sometimes not. There is no alternative offered. If you want something else, it is peanut butter jelly. There are no snacks, I have to buy my own. The food is always late. During an interview on 6/20/23 at 1:45 PM, Resident 64 stated, The food is lousy. I cannot eat a lot of the food. I have talked to dietary about preferences. Why do they ask if they aren't going to give it to you? I do not get my preferences usually. They say they have to cook for so many that they cannot see the preferences all the time. The food is cold. During an interview on 6/20/23 at 10:00 AM, Resident 82 stated, The food sucks. It tastes bad. You can't send it back. During an interview on 6/23/23 at 11:30 AM, Licensed Vocational Nurse 2 confirmed Resident 10 did not get her preferences on 6/21/23 and on a regular basis. LN 2 stated, They usually forget Resident 10's lettuce and tomato on her meal tray, it is on her meal ticket. We tell the kitchen, but they need more staff.

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 policy and procedure review, the facility failed to ensure the policy titled, Foods Brought by Family/Visitors' dated 3/2022, was implemented. These failures posed the risk of resident food brought to the facility from the outside not being handled in a safe manner which posed the risk of food borne illnesses. Findings: During a review of the facility's policy and procedure titled, Foods Brought by Family/Visitors' dated 3/2022, indicated in part .: 3. Family/visitors are asked to prepare and transport food using safe food handling practices including: a. Safe cooling and reheating processes beholding temperature apprehending cross contamination with raw or undercooked foods d. Hand hygiene 4. Safe food handling practices are explained to family/visitors in a language and format they understand. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. a. Nonperishable foods are stored in re-sealable containers with tightly fitting lids in. Intact fresh fruit may be stored without a lid. B. Perishable foods are stored in re-sealable container with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. 6. The nursing staff will discard perishable food on or before the use by date. During an interview on 6/21/2023 at 8:59 AM with LVN 1, LVN 1 stated, she would educate the family regarding the resident's diet. LVN 1 stated the food can be stored for 48 hours then will be discarded. During an interview on 6/21/2023 at 9:02 AM with LVN 2, LVN 2 stated, outside food could be kept for 24 hours and then would be discarded. LVN 2 stated she would educate the family and resident about discarding food after 24 hours. LVN 2 stated she was not sure if she had been educated on safe food handling practices. During an interview on 6/21/2023 at 9:05 AM with DSD, DSD stated, she was not aware of any staff training on safe food handling. DSD stated she would look in the old records for any training on safe food handling regarding for outside food. DSD was unable to provide any documentation of staff training on safe food handling regarding outside food. During an interview on 6/21/2023 at 9:15 AM with DON, DON stated, food brought from the outside should be dated, labeled, and kept for 72 hours then needed to be discarded. DON stated there may be a policy about outside foods, but it is not part of the nursing admission packet. When asked how visitors were educated on safe food handling the DON confirmed there was no written information regarding outside food handling given to the family or resident as part of the nursing admission. During an interview on 6/21/2023 at 9:17 AM with admission Coordinator (ADC), ADC stated, she would verbally inform the family that only nonperishable foods can be brought in for the resident. ADC confirmed there was no written information regarding outside food handling given to the family or resident as part of the admission packet.

CONCERN (D)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure one of three trash bin lids were tight fitting when one of three lids had a hole. This had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility. Findings: According to the USDA Food Code 2022 Section 5-501. 113 Covering Receptacles, Receptacles and waste handling units for refuse, recyclables, and return tables shall be kept covered: (B) with tight fitting lids or door if kept outside the food establishment. Review of the facility's policy and procedure titled, Dispose of Garbage and Refuse, dated 8/2017, indicated, all garbage and refuse will be collected and disposed of in a safe manner. Appropriate lids are provided for all containers. On 6/20/2023 at 3:05 PM an observation of the trash bins located in the rear parking lot and concurrent interview was conducted with the Director of Maintenance (DM). The lid on the recycle bin used for cardboard boxes had an open area on one of the two lids. DM confirmed there was an open area on the trash bin lid and needed to be fixed.

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one of six sampled residents, (Resident 303) received communication in a language that she could understand and verbalize needs in order to make informed care choices and decisions, when the resident only spoke Spanish and no interpreter services were used in the facility. This failure had the potential for the resident's needs and preferences not being met and the potential for complications of health status related to recent heart valve replacement and diabetes. Findings: During a review of a policy not dated, titled Translation and/or Interpretation of Facility Services, indicated the facility's language access program will ensure residents with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. Competent oral translation of vital information that is not available in written translation shall be provided in a timely manner at no cost to the resident through the following means: A Telephone interpretation service. Interpreters and translators must be appropriately trained in medical terminology. During a review of a new account dated 4/14/23 titled New Account for Language Line Personal Interpreter. indicated a language line is set up for all staff to use for communication, professional interpreters 24 hours a day and seven days a week, access from any phone or device. During a record review, Resident 303 was admitted to the facility on [DATE] and the primary language indicated Spanish, Castilian (the standard form of Spanish). During a record review, Resident 303 was admitted to the facility on [DATE] with diagnoses that included cardiac disease with a recent heart valve replacement, diabetes, and kidney disease. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 303 dated 6/9/23, indicated that Resident 303 had a brief interview for mental status (BIMS) score of 14, no noted cognitive impairment and was her own responsible party. During an interview on 6/20/23 at 10:24 AM, a Certified Nursing Assistant (CNA) B stated, We have a lot of staff to interpret, I do not use a language line. A lot of staff speaks [NAME], and some of the staff speaks Spanish. I look for gestures and try to ask by pointing. During an observation and interview at 10:49 AM, the Speech Therapist called the language line. Through the professional translator via cell phone, Resident 303 stated, My head hurts a lot, a 10. I want the white pill to make it stop. It has hurt a long time today, yes, a pain scale of 10 being the worst pain. I want water with my white pill to make it stop, pointing to forehead. During an interview on 6/20/23 at 10:55 AM, CNA J stated, I have never used the language line, I just get a CNA or any staff that speaks Spanish. I have been here since December 2022. I do not have the language line. I just try different things for the resident. I think she wants to get out of bed, I will get someone to help me. During an observation and interview at 11:10 AM, the Speech Therapist continued to hold the phone for translation. Through the professional translator Resident 303 stated, I do not want to get up, my head hurts. I just need a pillow behind me, but I do not want to get out of bed. During an interview on 6/21/23 at 8:39 AM, the Director of Nursing stated, We look at things different here. The staff should have access to the translation line, but it is so much easier and faster if a staff member is present. I rely on my staff to translate, and there was a lot going on with Resident 303. Resident 303 is discharging to another facility, leaving today and is nervous and anxious. Resident 303 wants to be home, but the family cannot take her home until she can walk. During an interview on 6/21/23 at 8:42 AM, the Assistant Director of Nursing stated, Resident 303 is a poor historian, I worked that cart with a student, and she had chest pain. Her family came in and it was just heart burn. No, I did not follow up with the chest pain. During an interview on 6/22/23 at 8:30 AM, the Administrator (Admin) confirmed the language line should be used for all staff to communicate and a translator is necessary for needs to be met and for health-related questions for safety and a copy of the translation line provided. The admin stated, I think I am going to get communication boards for the residents who do not speak English as their first language. The communication boards can help all shifts with questions related to activities of daily living like food, drinks, and toileting. The residents need this in their room as well as the translation line. During an interview on 6/23/23 at 9:08 AM, the Director of Staff Development confirmed the staff needs education and training to use the translation line. DSD stated, We have been using the staff to translate, but I understand how they need a professional translator to meet all their health concerns and needs.

CONCERN (E)

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

Deficiency F0565 (Tag F0565)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident complaints were acted upon timely and implement plans of action to correct the identified issues. This failure resulted in ongoing unresolved complaints. Findings: A review of a facility policy titled Resident Council revised February 2021, indicated the purpose of the resident council was to provide a forum for residents/families to have input in the operation of the facility. They can discuss their concerns and suggestions for improvement. A resident council response form will be used to track their resolution. The facility department will be responsible for addressing the item of concern. The quality assurance and performance improvement (QAPI) will review information and feedback from the council and may be referred to the committee when there was a pattern in the issue the council identified. A review of the resident council meetings minutes indicated: On 10/27/22, dietary services spoke to the resident about consistency on time that the meal carts come out from the kitchen. Two out of eights residents stated they are not offered supplies for mouth hygiene. Five out of the eight residents stated they have not had a shower in a long time. On 11/20/22, dietary services explained to the residents how he was fixing the snacks problem, to ensure they are always available. A resident on Hall 2 stated she had waited over one hour today for personal care and was wet as a result. A resident stated residents that need assistance in the dining room are not receiving help then staff take their trays away. On 12/28/22, a resident stated she was having to wait a long time for her call light to be answered and continued, unresolved. A review of a the nursing department response indicated remind Certified Nursing Assistants (CNAs) to answer call lights in a timely manner, this was the same response for 11/20/22. On 1/25/23, old business waiting too long call lights, still in progress, unresolved. New business resident on Hall 3 stated food was almost always cold. Resident on Hall 3 stated snacks are not available. On 2/22/23, new business resident on Hall 3 stated food was always cold and snacks are not available. Resident satisfaction questions the resident response was snacks were not always available. On 4/26/23, no old business. On 5/24/23, new business resident on Hall 1 and Hall 3, had concerns about food coming out cold and late. Residents on Hall 5 and Hall 4 had concerns about water coming out late in the afternoon. There was no response from dietary services about food being cold and food trays coming out late. A review of a facility policy titled Frequency of Meals revised July 2017, indicated breakfast will be served at 7 AM, lunch at 12 PM, and dinner at 5 PM. Nourishing snacks will be available for residents who need or desire additional food between meals. A policy titled Meal distribution: revised September 2017, indicated meals are to be transported to dining locations in a timely manner. During an interview on 6/20/23 at 9:44 AM, Resident 91 food was late and the food was cold. During observations of dining room and facility hallways on 6/20/23 starting at 11:43 AM, Infection Preventionist (IP) stated lunch usually comes out from 12-12:30 PM, sometimes its 1230 PM. At 12:31 PM, Resident 68 stated lunch comes around 1230 PM it is always late, she left because it's too late. Resident 68 returned a few minutes later when meal arrived 12:54 PM. At 12:40 PM, Resident 57 stated every day the food was late just for lunch time, he was starving and was not happy, meal trays came at 12:54 PM. At 12:43 PM, Resident 70 stated food sometimes cold, often late. During hallways observations during meal tray delivery for lunch on 6/20/23 at 1 PM, room [ROOM NUMBER] C and room [ROOM NUMBER] A still waiting for meal trays. At 1:02 PM, food cart 2 was sitting in hallway with unpassed trays. During the passing of meals trays direct care staff stop to help multiple residents which slows the process. Multiple call lights blinking. During an interview 6/27/23 at 11:02 AM, Administrator (ADMIN) stated the expectation for resolving resident council issues is the same as grievances, with the exception of it being resolved within 72 hours. ADMIN stated based off of the issues, we might do a call light study, or I would observe the timing of when the trays come out for each meal.

CONCERN (E)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the right to personal privacy for all residents who showered when there was no system for communicating when a shower was or was not in use without opening the door. This failure had the potential to cause distress for the residents and threaten their health and well-being. Findings: During a concurrent observation and interview, on 6/20/23, at 9:50 AM, Certified Nursing Assistant (CNA) M opened the door to the shower room across from room [ROOM NUMBER]. CNA M used the keypad combination lock. An unknown resident was in a shower chair, bathing in the shower stall. When asked if there was any way to know if the shower was in use before opening the door, besides listening for the sound of running water, CNA M said no. There was no sign outside the door to indicate a resident was bathing. Soon a second staff member attempted to open the shower room door using the keypad before being told someone was already in the shower. During an interview, on 6/20/23, at 3:22 PM, CNA N stated they usually knocked on the shower door and listened for a verbal response. Sometimes residents showered by themselves and called out. There was no sign outside door and no other communication system except to knock on the door and to speak through the door to determine if someone was in there. During an observation, on 6/20/23, at 3:25 PM, a male CNA took an unknown female resident in a shower chair into the shower and closed the door. Nothing on the outside of the room indicated that the shower was in use.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Vertical blinds were broken in room [ROOM NUMBER]. During a review of a policy revised 6/2016, titled Deep Clean Check Off List, indicated the residents' rooms must be disinfected, dusted, and dirt free when you are done. This policy indicated to clean and wipe down doors, door jams, and door frames. This policy also indicated to clean and wipe down all tables, nightstands and rolling tables. During a review of a policy revised 12/2009, titled Maintenance Service, indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. This policy stated the maintenance service is to maintain the building in good repair and free from hazards, establish priorities in providing repair service, and provide routine scheduled maintenance service to all areas. During a record review, Resident 300 was admitted to the facility on [DATE] for diagnoses that included heart disease, kidney disease, generalized muscle weakness, and high blood pressure. During a record review, Resident 301 was admitted to the facility on [DATE] for diagnoses that included heart disease, end stage kidney disease, respiratory failure, and diabetes. During a concurrent observation and interview on 6/20/23 at 10:10 AM, room [ROOM NUMBER]'s vertical blinds were not in working order and could not be opened or closed at the sliding glass door. There was a white soiled bathing blanket hung on the left side of the window, and Resident 303 stated, I don't know who hung that blanket up there, it looks dirty to me. I wanted the window open. Cumulative dirt noted around the inside of the sliding door, black build up of grime, and actual pollen was inside the sliding door frame. room [ROOM NUMBER] was disorganized, Hoyer lift pad soiled in the wheelchair, and the room was cluttered. The floor was sticky and had soiled black colored build up around the bed side table. During an observation on 6/20/23 at 10:15 AM, room [ROOM NUMBER]'s sliding screen door (a door that consists of a frame holding metallic or plastic netting used for ventilation and used to keep insects from entering the building) was noted to have multiple holes, did not slide properly to be functional. The screen had a bent frame and the mesh had multiple holes, so severe you could not see through the screen door. The damaged screen door made the room look outdated, unkept and unclean. 4. Screens were in disrepair with holes in rooms 24, 30, 32, 34, and 35. During a review of a record, Resident 10 was admitted to the facility on [DATE] with diagnoses that included diabetes, heart disease, and high blood pressure. During a record review, Resident 33 was admitted to the facility on [DATE] for diagnoses that included high blood pressure, stroke, and vascular dementia. During a record review, Resident 58 was admitted to the facility on [DATE] for diagnoses that included a stroke, epilepsy, ( a type of seizure disorder) and high blood pressure. During an observation on 6/20/23 at 9:47 AM, room [ROOM NUMBER]'s sliding screen door (a door that consists of a frame holding metallic or plastic netting used for ventilation and used to keep insects from entering the building) was noted to have multiple holes, did not slide properly to be functional. The screen had a bent frame and the mesh had multiple holes, so severe you could not see through the screen door. The damaged screen door made the room look outdated, unkept and unclean. During this observation on 6/20/23 at 9:47 AM, room [ROOM NUMBER] was visible unclean. Dirt and black grime build up noted around the entire wall of the sliding door, base boards of the room, facing the courtyard. The floor was sticky, black colored stains on the floor and appeared unkept with cumulative dust in the sliding glass door corner. Multiple areas of this room had extra linen, untidy and bedside tables were full and had sticky substances on the surfaces. During a record review, Resident 17 was admitted to the facility on [DATE] for diagnoses that included a stroke, diabetes, high blood pressure, and generalized muscle weakness. During an observation on 6/20/23 at 9:55 AM, room [ROOM NUMBER]'s sliding screen door (a door that consists of a frame holding metallic or plastic netting used for ventilation and used to keep insects from entering the building) was noted to have multiple holes, did not slide properly to be functional. The screen had a bent frame and the mesh had multiple holes, so severe you could not see through the screen door. The damaged screen door made the room look outdated, unkept and unclean. The room was a private room and had chipped paint behind and beside the bed. There was cumulative dirt and black colored grime in the door frame. During a record review, Resident 29 was admitted to the facility on [DATE] for diagnoses that included diabetes, kidney disease, dementia and high blood pressure. During a record review Resident 21 was admitted to the facility on [DATE] for diagnoses that included Parkinson's disease, (a progressive brain disorder that gets worse over time causing tremors, stiffness and balance problems), dementia, and repeated falls. During an observation on 6/20/23 at 9:59 AM, room [ROOM NUMBER]'s sliding screen door (a door that consists of a frame holding metallic or plastic netting used for ventilation and used to keep insects from entering the building) was noted to have multiple holes, did not slide properly to be functional. The screen had a bent frame and the mesh had multiple holes, so severe you could not see through the screen door. The damaged screen door made the room look outdated, unkept and unclean. There was cumulative dirt and black colored grime in the door frame. During a record review, Resident 302 was admitted to the facility on [DATE] for diagnoses that included fracture of left ankle, high blood pressure and other disorders of bone density. During a record review, Resident 303 was admitted to the facility on [DATE] with diagnoses that included cardiac disease with a recent heart valve replacement, diabetes, and kidney disease. During an observation on 6/20/23 at 10:19 AM, room [ROOM NUMBER]'s sliding screen door (a door that consists of a frame holding metallic or plastic netting used for ventilation and used to keep insects from entering the building) was noted to have multiple holes, did not slide properly to be functional. The screen had a bent frame and the mesh had multiple holes, so severe you could not see through the screen door. The damaged screen door made the room look outdated, unkept and unclean. During an observation on 6/20/23 at 10:21 AM, the sliding glass door for room [ROOM NUMBER] would not lock, it was attempted several times, but would not latch and close completely. During an interview on 6/22/23 at 09:10 AM, Administrator ([NAME]) confirmed all sliding door areas are dirty, screens need replaced for rooms 24, 30, 32, 34, and 35. Admin also confirmed sliding door does not lock for room [ROOM NUMBER] and will be fixed immediately, and all the rooms observed were visible soiled, sticky, and needed extensive cleaning. Admin stated she will update the contract service deep cleaning is indicated. During an interview on 6/22/23 at 10:10 AM, the Director of Maintenance, (DM) stated. Yes, I have worked on the screens for 6 months now, I talked to the company across the street, we have added to Quality Assurance and Performance Improvement, (QAPI). DM confirmed the screens for rooms 24, 30, 32, and 34 had broken and worn screens that do not slide, visible holes. DM also confirmed he will fix the lock on the sliding door for room [ROOM NUMBER]. During an interview on 6/22/23 at 2:10 PM, Housekeeper (HSK) B stated, I clean the resident rooms every day, including the sliding doors and all areas. We do the wheelchair cleaning every weekend for all residents. During an interview on 6/22/23 at 2:23 PM, the Housekeeping District Manager, (HSKDM) confirmed she bought new cleaning products and sponges for residents' sliding room doors, around screens, etc. HSKDM stated, Yes, the administrator already talked to me about cleaning the rooms around the sliding glass door and all of resident's rooms daily, clean wheelchairs weekly on the weekends, provided a cleaning schedule and complete deep cleaning. 5. a picture was not hung on the wall and a piece of furniture not assembled for resident 24. During a concurrent observation and interview on 6/20/23 at 10:00 AM with Resident 24, a large picture, the size of a poster, with the image of a red rose which was contained in a lightweight poster frame with what appeared to be a plexiglass cover, was noted on the floor leaning against the west wall of the resident's room. The wall was painted purple but had several areas of discolored patching on the wall. There were a few nails and screws in random areas on the walls, but many had obviously been removed. It was observed the resident room had very minimal personal items as décor. Additionally, a medium brown box that appeared to have not been opened was on the floor by the resident's bed. Resident 24 stated, I have a picture, the rose picture on the floor, that I really love. They will not put it up. Maintenance does not want to put nail holes in the wall and won't let me put it up by other means, like with that special tape. They say it might hurt someone if it fell. They say it is too heavy. It is very lightweight. Surveyor lifted picture to gauge its weight, found to be very light. I have had this picture up in most of the rooms since I have been in here, but now they say I can't put it up. They also say that they will not put my charging table together. It was a gift, and it charges ipads and phones. It is in the box by my bed. The maintenance man told me I have too many items in my room and even though there is no one in the B bed area, I cannot use that outlet for my table because someone might move there. I would plug it somewhere else if someone moved into bed B. That bed has been empty for a very long time. He was very gruff with me, he just told me, No, he wouldn't do either of those requests. I talked to SSD (Social Services Director) about it, all she said was I'll see what I can do. I am getting so angry. I have seen other rooms with things on their walls, I feel like I am being singled out. Review of the facility's policy titled, Personal Property dated March 2021 indicated that Residents are permitted to retain and use personal possessions, including furniture and clothing, as space permits, unless doing so would infringe on the rights or health and safety of others. The policy states further that resident's personal belongings and clothing are inventoried and documented upon admission and updated as necessary, and that the facility promptly investigates any complaints of misappropriation or mistreatment of resident property. During a review of Resident 24's record on 6/21/23 at 7:30 AM, it indicated that Resident 24 was admitted on [DATE] had been conserved by the Sutter County Public Guardian's office. Resident 24 diagnoses include Alzheimer's (progressive brain disease that affects memory and other important mental functions), Schizoaffective Disorder, Bipolar type (mental health disorder with hallucination, delusions, depression, and mania), and Interstitial lung disease (disorder that causes progressive scarring of the lungs affecting the ability to breathe). The facility's MDS (minimum data set, a standardized assessment tool) dated 5/20/23, rated Resident 24's cognition 9/15, moderately impaired. During an interview on 6/22/23 at 8:30 AM with DM (Director of Maintenance), stated, I don't remember who told me initially about the picture. It may have been the resident caught me walking by and told me about wanting the picture hung. The SSD (Social Services Director) also told me. I do not know if a maintenance request was created. I am familiar with the picture. It is very heavy with a heavy glass frame. It is a gigantic picture of a rose. She has had it hung in other rooms, but it fell off the wall in one of the previous rooms and it could have hurt someone. I did not document anything. I don't think there is any documentation about the picture, or when it fell. We are about to redecorate rooms, paint, and get new furniture as soon as we finish the lobby. We are trying not to put a bunch of holes in the walls with nails, that is true. Pictures can be hung with the special tape. I will have to go see the picture again and test the weight. I did not put the table together because it has an unapproved electrical device. It is very technical as to what is approved. I do not have documentation to show which electrical devices are approved and which are not. That room is not large enough for her to have another table. She cannot take over the area for Bed B. During an interview on 6/22/23 at 9:30 AM with SSD (Social Services Director), stated, I don't believe a maintenance request was filled out, I think Resident 24 pulled me in from the hallway as I was walking by and asked me to see about getting her picture hung. I told her I would see what I could do. I told the DM. I did not fill out anything. The picture is very heavy, it has glass in the front. It is a big picture of a rose. It was hung in that room by the bathroom, but it fell, and I think the glass broke or something. It was definitely that room which she has been in since 1/13/23. I don't know what DM told her because I was not in the room. I do not see any notes about the picture, I did not make notes, or follow-up. The DM does a list of things to do to follow-up. During an interview on 6/22/23 at 10:10 AM with Admin (Administrator), stated, I am aware of the picture not being hung. I understand that it is a very heavy glass framed picture that fell before and could be a hazard. I personally have not looked at it. I don't know about the table, but I will check into the electrical device with my resource to see if it can be used. I will go look at both the picture and the table before any further determination. During an interview on 6/22/23 at 1:40 PM with Admin, stated, I should have looked at that from the start, the picture was very light. It is being hung by MA (Maintenance Assistant) , and my resource said the table can be put together and attached to an approved electrical device, so the table is being put together as well. During a concurrent observation and interview on 6/23/23 at 10:30 AM with MA. The large picture of the rose was viewed hanging on the west wall of the resident's room. MA stated, it wasn't heavy, just flimsy. I hung it with a nail and adhesive to seal. The maintenance requests can be filled out by anyone and are located at the nurse's stations which is the usual way for us to follow. Based on observation and interview, the facility failed to provide a clean, safe, comfortable and homelike environment for ten of ten sampled residents (Residents 10, 17, 21, 24, 29, 33, 51, 58, 300, and 302) when: 1. The walls were in disrepair in room [ROOM NUMBER]. 2. A screen was protruding from the window in room six. 3. Vertical blinds were broken in room [ROOM NUMBER]. 4. Screens were in disrepair with holes in rooms 24, 30, 32, 34, and 35. 5. A picture was not hung on the wall and a piece of furniture not assembled for Resident 24. This failure had the potential to allow pests to enter through the open windows and to create a visually unpleasant environment, both of which could have negatively impacted the residents' health and well-being. Findings: 1. A review of Resident 51's clinical record showed they were admitted to the facility on [DATE]. Resident 51's diagnoses included psychosis (a loss of touch with reality), anxiety, and depression. During an observation, on 6/20/23, at 2:39 PM, Resident 51 was lying on his bed, curled up on his left side, facing the wall. Resident 51's hands rested against a patch of dry, unfinished plaster on the wall which had gouges in it. During a concurrent observation and interview, on 6/20/23, at 2:41 PM, Housekeeper (HSK) A confirmed areas of chipped paint, unfinished plaster, a worn area where Resident 51's hand rubbed against the wall, areas that had been patched but not painted above the bed in 41B, paint rubbed off the doorframes in the bathroom between rooms [ROOM NUMBERS], and paint peeling on the wall next to the toilet. 2. During a concurrent observation and interview, on 6/22/23, at 7:37 AM, the DM confirmed that a window screen was protruding from the window for room six and was not secured.

CONCERN (E) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure direct care and administrative staff reported allegations of staff to resident abuse to the mandated agencies for three of three sampled residents (Resident 63, 74 and 86). This had the potential to put all residents at risk for abuse from staff at the facility. Findings: A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Identify and assess incidents of abuse. Investigate and report any allegations for abuse within the timeframes as required by federal requirements. Protect residents during the abuse investigations. A review of the resident concern and grievance log, indicated from 2/2-6/10/23, seven out of 11 resident complaints listed the concern was related to nursing and Certified Nursing Assistant (CNA) care. A review of the resident grievance/complaint form dated 2/2/23, the Social Service Director (SSD) documented Resident 63's complaint that CNA E (agency registry staff) took his call light device and television (TV) remote away from him, so he could not use it. Resident 63 explained at 2 AM on 2/1/23, he yelled and hollered for help so he could use the restroom, CNA E told him to go (urinate) in his continence briefs. Resident 63 further explained at some point he got the TV remote back and not the call light device, and needed help again, so he turned up the volume on TV to get a CNA's attention. Resident 63 stated he was told I'm not the only person here that needs help. Under names and person involved it indicated Unknown CNA (registry). Under actions or recommendations do you feel need to be taken, there was nothing documented. On the concern/grievance log for 2/2/23, the concern was listed unhappy with CNA care, the staff members assigned to follow-up with SSD and Nursing Home Administrator (ADMIN). Resolution area indicated inservice (education) CNA, and registry agency called to inform facility did not want CNA E to be invited back to work. A review of a resident grievance/complaint form dated 2/17/23, indicated a Physical Therapy Assistant (PTA) documented that Resident 74 reported CNA C seems to be upset for caring for him and that his needs are not being met by this CNA. Under actions indicated room change or CNA change. On the concern/grievance log on 2/17/23 indicated the SSD was to follow-up and resolution was a room move for resident. A review of a resident grievance/complaint form dated 5/24/23, PTA documented that Resident 86 stated that CNA A does not attend to her when needed. CNA A does not assist Resident 86 when she wants to use the bathroom, get changed or go to bed. Resident 86 stated CNA A has outbursts when she asked her for assistance and helps her only when she has time not when Resident 86 requested help. On the concern/grievance log dated 5/24/23, the assigned staff member to follow-up was Director of Nursing (DON) and SSD, the resolution was CNA A was removed from Resident 86's hallway. During an interview on 6/22/23 10:30 AM, Director of Rehabilitation (DOR) reviewed the resident grievance complaint form for Resident 74 and 86 that PTA had filled out. DOR stated confirmed she spoke with PTA about Resident 86's allegation but not Resident 74. DOR was asked about the difference between customer service and an abuse allegation, she confirmed that not providing care and the word outbursts should have been reported by PTA. DOR further explained, she did not direct PTA to report the resident allegation to the appropriate agencies. DOR stated, we are instructed to report to administration. During a concurrent interview and record review on 6/22/23 at 10:50 am, with SSD and Social Service Assistant (SSA), they both read the grievance complaint forms for Residents 63, 74, and 86. SSD stated when PTA came to her, she filled out the form and reported to 24 stand up (daily morning meeting to discuss changes) where all administrative discuss issues from the previous day. SSD was unsure if these were investigated and did not direct staff to report as an allegation of abuse. SSD stated there was not enough detail to determine if it should be reported. SSD and SSA both agreed that the word outburst and refusing should have been reported to the appropriate agencies and should be investigated. During a concurrent observation and interview on 06/22/23 at 3:50 PM, Resident 63 remembered the complaint he had about a CNA E back in February 2023. Resident 63 was in a special wheelchair due to being contracted in both arms and legs. Resident 63 stated she was rough and threw him in his bed and took my call light device so I could not call for help. During a concurrent interview and record review on 6/22/23 2:45 PM, the Administrator (ADMIN) reviewed her abuse files left by previous ADMIN and confirmed there was no record of these allegations being reported or investigated. ADMIN reviewed the grievances made by Resident 63, 74 and 86 and confirmed these did not belong in the grievance process and should have been reported to California Department of Public Health (CDPH) and Ombudsman per facility abuse policy. ADMIN confirmed they were not investigated and did not know which CNA registry was the alleged perpetrator. Admin confirmed the staff should have reported the alleged abuse allegation as being mandated reporters. During a concurrent interview and record review on 6/26/23 at 10 AM, the DON confirmed the PTA and SSD needed to report the alleged abuse for Resident 63, 74 and 86. DON was not informed about the CNA E (registry) incident with Resident 63, and it was not investigated and should have been reported to CDPH, Ombudsman, police and should have been protected while it was investigated.

CONCERN (E)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to ensure allegations of staff to resident abuse were investigated and residents were protected during this process for three of three residents (Residents 63, 74 and 86). This put all residents at risk for staff to resident abuse. Findings: A review of a facility policy titled Abuse Prevention Program revised December 2016, indicated residents have the right to be free from abuse, neglect, misappropriation of property, verbal, mental, sexual, and physical abuse. Protect residents during the allegation of abuse investigations. A review of the resident grievance/complaint form dated 2/2/23, the Social Service Director (SSD) documented Resident 63's complaint that CNA E (agency registry staff) took his call light device and television (TV) remote away from him, so he could not use it. Resident 63 explained at 2 AM on 2/1/23, he yelled and hollered for help so he could use the restroom, CNA E told him to go (urinate) in his continence briefs. Resident 63 further explained at some point he got the TV remote back and not the call light device, and needed help again, so he turned up the volume on TV to get a CNA's attention. Resident 63 stated he was told I'm not the only person here that needs help. Under names and person involved it indicated Unknown CNA (registry). Under actions or recommendations do you feel need to be taken, there was nothing documented. On the concern/grievance log for 2/2/23, the concern was listed unhappy with CNA care, the staff members assigned to follow-up with SSD and Nursing Home Administrator (ADMIN). Resolution area indicated inservice (education) CNA, and registry agency called to inform facility did not want CNA E to be invited back to work. A review of a resident grievance/complaint form dated 2/17/23, indicated a Physical Therapy Assistant (PTA) documented that Resident 74 reported CNA C seems to be upset for caring for him and that his needs are not being met by this CNA. Under actions indicated room change or CNA change. On the concern/grievance log on 2/17/23 indicated the SSD was to follow-up and resolution was a room move for resident. A review of a resident grievance/complaint form dated 5/24/23, PTA documented that Resident 86 stated that CNA A does not attend to her when needed. CNA A does not assist Resident 86 when she wants to use the bathroom, get changed or go to bed. Resident 86 stated CNA A has outbursts when she asked her for assistance and helps her only when she has time not when Resident 86 requested help. On the concern/grievance log dated 5/24/23, the assigned staff member to follow-up was Director of Nursing (DON) and SSD, the resolution was CNA A was removed from Resident 86's hallway. During a concurrent interview and record review on 6/22/23 at 10:50 AM, with SSD and Social Service Assistant (SSA), they both read the grievance complaint forms for Residents 63, 74, and 86. SSD stated when PTA came to her, she filled out the form and reported to 24 stand up (daily morning meeting to discuss changes) where all administrative discuss issues from the previous day. SSD was unsure if these were investigated. SSD stated there was not enough detail to determine if it should be reported. SSD and SSA both agreed that the word outburst and refusing should have been reported to the appropriate agencies. During a concurrent observation and interview on 06/22/23 at 3:50 PM, Resident 63 remembered the complaint he had about a CNA E back in February 2023. Resident 63 was in a special wheelchair due to being contracted in both arms and legs. Resident 63 stated she was rough and threw him in his bed and took my call light device so I could not call for help. During a concurrent interview and record review on 6/22/23 2:45 PM, the Administrator (ADMIN) reviewed her abuse files left by previous ADMIN and confirmed there was no record of these allegation being reported or investigated. ADMIN reviewed the grievances made by Resident 63, 74 and 86 and confirmed these did not belong in the grievance process and should have been reported to California Department of Public Health (CDPH) and Ombudsman per facility abuse policy. ADMIN confirmed they were not investigated and did not know which CNA registry was the alleged perpetrator. During a concurrent interview and record review on 6/26/23 at 10 AM, DON was not informed about the CNA E (registry) incident with Resident 63, and it was not investigated and should have been reported to CDPH, Ombudsman, police and the resident should have been protected while it was investigated.

CONCERN (E) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of a policy revised March 2018, titled Activities of Daily Living (ADL), Supporting indicated residents who are unable to carry out adls independently will receive the services necessary to maintain good nutrition, grooming and personal hygiene. This policy indicated hygiene (bathing) will be provided for residents who are unable to carry out independently, as scheduled, as needed, and per resident request. During a review of a record, Resident 23 was admitted to the facility on [DATE] with diagnoses that included Guillain-Barre Syndrome, (a rare disorder in which your body's immune system attacks nerves, eventually paralyzing the whole body), high blood pressure, and dependence on wheelchair. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 23 dated 4/14/23, indicated that Resident 23 had a slight cognitive deficit, with a brief interview for mental status (BIMS) score of 12, but was her own responsible party, and required extensive assistance with transfers, toileting, and bathing. During a record for Resident 23, documents titled, Intervention/Task bathing, Resident 23 only received two baths from June 1, 2023, through June 21, 2023. Resident 23 received only five baths for the entire month of May 2023, three baths for the entire month of April 2023, and five baths in March 2023. There were no documented refusals of bath/shower for any of these months from March through June and no progress notes from nursing staff. During a record review, Resident 29 was admitted to the facility on [DATE] for diagnoses that included diabetes, kidney disease, dementia and high blood pressure. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 29 dated 4/6/23, indicated that Resident 29 had a severe cognitive deficit, with a brief interview for mental status (BIMS) score of 5 and required extensive assistance with transfers, toileting, and bathing. During a record for Resident 29, documents titled, Intervention/Task bathing, Resident 29 only received one bath from June 1, 2023, through June 21, 2023. Resident 29 received five baths for the entire month of May 2023, and five baths in March 2023. There were no documented refusals of bath/shower for any of these months from March through June and no progress notes from nursing staff. During a record review, Resident 33 was admitted to the facility on [DATE] for diagnoses that included high blood pressure, stroke, and vascular dementia. A review of the most recent Minimum Data Set, (MDS, a resident assessment tool) for Resident 33 dated 4/6/23, indicated that Resident 23 had a slight cognitive deficit, with a brief interview for mental status (BIMS) score of 12, but was her own responsible party, and required extensive assistance with transfers, toileting, and bathing. During a record for Resident 33, documents titled, Intervention/Task bathing, Resident 33 only received no baths from June 1, 2023, through June 21, 2023. five baths for the entire month of May 2023, seven baths for the entire month of April 2023, and four baths in March 2023. There were no documented refusals of bath/shower for any of these months from March through June and no progress notes from nursing staff. During a record review, Resident 302 was admitted to the facility on [DATE] for diagnoses that included fracture of left ankle, high blood pressure and other disorders of bone density. During a record review for Resident 302, the Minimum Data Set, (MDS, a resident assessment tool) had not been completed as of 6/23/23. During an interview on 6/20/23 at 10:50 AM, the Director of Staff Development (DSD) confirmed Resident 302 was alert and oriented, able to verbalize needs, and a new admission to the facility. During an interview on 6/20/23 at 10:45 AM, Resident 302 stated, I did not get my shower this Monday as scheduled. I have asked but no one has given me one. During a record for Resident 302, documents titled, Intervention/Task bathing, Resident 302 only received one baths from June 14, 2023 through June 20, 2023. There were no documented refusals of bath/shower for any of these days for June 2023 and no progress notes from nursing staff. During an interview on 6/22/23 at 8:52 AM, the Administrator (Admin) confirmed bathing was not completed as scheduled for residents 23, 29. 33 and 302. Admin stated, This is a problem, we need to make sure all residents are getting baths/showers per the schedule. We are definitely having an in-service to fix this process, this is unacceptable. During an interview on 6/23/23 at 8:59 AM, DSD confirmed the nursing staff needs more education and all bathing/ showers should be completed on scheduled days and as needed. DSD stated, The Certified Nursing Assistants (CNA)s update the medication nurses on the hall, they are supposed to let the nurses know if the resident refuses. The nurse will document and then go help encourage the resident to take their bath or shower. We should try different times, different staff if the resident continues to refuse. Yes, it is a dignity problem when the residents do not receive baths. We have in-services for Dementia care every year. Yes, I agree the staff needs more training, both the CNAs and the nurses. Based on observation, interview, and record review, the facility failed to ensure that six of six sampled residents (Residents 23, 29, 32, 33, 64, and 302), received assistance with activities of daily living to attain or maintain their independence when: 1. Routine grooming activities were not completed for Resident 32 and Resident 64. 2. Routine and scheduled showers were not completed for Residents 23, 29, 33 and 302. These failures had the potential to result in the residents feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being. Findings: 1. A facility policy, titled, Fingernails/Toenails, Care Of, revised 2/1/18, was reviewed. It's stated purpose was to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care included daily cleaning and regular trimming. Documentation was to have included date, time, name and title of individual performing nail care, condition of the resident's nails, any difficulties, if the resident refused, and the staff member's signature. A review of Resident 32's clinical record showed they were admitted to the facility on [DATE]. Resident 32's diagnoses included schizophrenia (a thought disorder that caused hallucinations), diabetes (a disorder of blood sugar regulation), bilateral (both sides) cataracts (clouding of the eye lens that could cause blurred vision), and optic nerve atrophy (damage to the eye nerve that could lead to vision loss). During a concurrent interview and observation, on 6/20/23, at 2:27 PM, Resident 32 sat up in a chair next to their bed. Resident 32's fingernails were long and jagged. When asked about his nails, Resident 32 responded, I cut 'em. During a concurrent interview and observation, on 6/20/23, at 2:28 PM, Certified Nurse's Assistant (CNA) L confirmed Resident 32's fingernails were long and irregularly jagged with sharp edges. Review of Resident 32's Comprehensive CNA Shower Review sheets, dated 6/2/23 and 6/13/23, showed the question, Does the resident need his/her fingernails cut/cleaned?, had been marked, N for no. Review of Resident 32's electronic health record showed an expanded list of ADL task documentation done by CNAs for June 2023. There was no documentation done for the task titled, Salon/Nails. During a concurrent observation and interview, on 6/21/23, at 1:30 PM, with Resident 64, the resident's fingernails were observed to be very long, extending past his fingertips by approximately ½ inch. Resident 64 stated, My nails are too long. I have asked to have them cut a few times, but the staff got too busy and couldn't get to them. I have been here for about two and a half months and they have not cut them the whole time. A document, titled, In-service Training for Certified Nurse Assistants Attendance Sign-in Sheet, dated 5/3/23, was reviewed. In the Course Title line was, Nail Care, and Demo/Return Demo. The instructor was the DSD. During a concurrent interview and record review, on 6/21/23, at 3:27 PM, DSD stated that they did not write down any content or Lesson Plan for the nail care in-service done on 5/3/23, they just had the information in their head. When asked to describe what had been demonstrated, DSD described the materials and procedure, and said staff documented it on the shower sheets. If a resident was diabetic, the CNAs were instructed to talk to the licensed nurse about it. During a concurrent interview and record review, on 6/21/23, at 9:56 AM, the Director of Nursing (DON) stated that the shower sheets were the only place where nail care was documented.

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet the individual care needs for 14 out of 20 sampled residents (Residents 63, 26, 10, 15, 250, 33, 29, 23, 302, 32, 64, 68, 57 and room [ROOM NUMBER]) when: 1. Insufficient nursing staff to answer call lights to provide care to dependent residents. This resulted in residents to feel angry and neglected. 2. Showers and nail care were not provided. This had the potential for changes in resident skin conditions not to be identified and to feel undignified. 3. Certified Nursing Assistants (CNAs) performing Activities of Daily Living (ADL,resident care) during meal tray delivery. This resulted in residents to feel frustrated, hungry and food was cold. Findings: 1. A review of the Daily Staffing Sheets for the night shift (NOC, 10:30 PM to 7 AM) indicated: On 2/1/23, three out of five scheduled CNAs signed the sheet. On 2/2/23, three out of four scheduled CNAs signed the sheet. On an undated sheet, three CNAs were scheduled. On 2/3/23, four out of five CNAs signed the sheet. On 2/4/23, four out of five CNAs signed the sheet. On 2/5/23, two out of five CNAs signed the sheet. On 6/10/23, four CNAs signed the sheet. On 6/16/23, four CNAs signed the sheet. During a concurrent observation and interview on 06/22/23 at 3:50 PM, Resident 63 remembered the complaint he had about CNA E back on 2/1/23. Resident 63 was in a special wheelchair due to being contracted in both arms and legs. Resident 63 stated she was rough, and threw him in his bed and took my call light device so I could not call for help. Resident 63 stated NOC shift staff are all registry and do not have time to care for residents. Resident 26 confirmed staff do not come timely for call lights, often he has waited more than an hour when he was wet. Resident 26 stated he calls for assistance for Resident 63 who has to yell out for help. Resident 63 stated has to wait for more than an hour and both room mates stated this makes them angry. Resident 63 stated CNAs on this last Monday and Tuesday told him they were working doubles and staff talk about multiple admissions that come in which takes up their time. During an interview on 6/23/23 at 11:20 AM, Resident 10 stated they do not have enough staff, we only have three CNAs on NOC shift. Resident 10 explained the staff hide Bed C's call light because she uses it a lot and they get tired of answering it. During an interview on 6/20/23 9:57 AM, Resident 15 stated staff doesn't treat me good, and takes them a long time to change me, sometimes a whole day. Resident 15 stated staff not respectful, makes me feel terrible and I have told a lot of people. During an interview on 6/20/23 at 10:50 AM, Resident 250 stated staff take awhile to answer call light over 20 minutes, if I was to fall and I'm screaming they don't show up, that scares me. During an interview on 6/20/23, a room [ROOM NUMBER] resident stated NOC people suck they are lazy and and do not get my medications. 2. Resident 33, 29, 23, 302 did not receive scheduled showers; and Residents 32 and 64 had long, jagged fingernails for months. During an interview on 6/21/23 at 1:30 PM with Resident 64, stated, sometimes they are short staffed. I didn't get my shower on Monday, so they did it last night. They did not tell me why, but I think it was because they were short staffed. 3. During observations of dining room and facility hallways on 6/20/23 starting at 11:43 AM, Infection Preventionist (IP) stated lunch usually comes out from 12-12:30 PM, sometimes its 1230 PM. At 12:31 PM, Resident 68 stated lunch comes around 12:30 PM it is always late, she left because it's too late. Resident 68 returned a few minutes later when meal arrived 12:54 PM. At 12:40 PM, Resident 57 stated every day the food was late just for lunch time, he was starving and was not happy, meal trays came at 12:54 PM. At 12:43 PM, Resident 70 stated food sometimes cold, often late. During hallways observations during meal tray delivery for lunch on 6/20/23 at 1 PM, room [ROOM NUMBER] C and room [ROOM NUMBER] A still waiting for meal trays. At 1:02 PM, food cart 2 was sitting in hallway with unpassed trays. During the passing of meals trays direct care staff stop to help multiple residents which slows the process. Multiple call lights blinking. During an interview on 6/22/23 at 1:30 PM, CNA F stated, sometimes it was harder to provide care than other times because of staffing issues. CNA F stated we are better than it was, but we have times that we run with a small amount of staff and it made it hard to get everything done. During an interview 6/23/23 at 10:03 AM, Administrator (ADMIN) about staffing the facility. ADMIN stated the Director of Staff Development (DSD) has worked the floor two days in 6 weeks to pass medications and does not like to do that. ADMIN stated they are short direct care staff on evening shift and have advertisements out to hire CNAs. ADMIN stated admissions are averaging about 5 a week, census was at or just below 100 residents. Admin stated four CNAs on NOC shift was not adequate to meet needs of residents. During an interview on 6/23/23 at 10:45 AM, DSD stated she has worked two times on the evening shift for administering medications, and one time day shift for staff calling out. DSD confirmed four CNAs not enough on NOC shift. During a concurrent interview and record review on 6/26/23 at 10 AM, Director of Nursing (DON) stated direct care staffing has been difficult over the past year. DON stated she does not want to use registry, reviewed NOC shift staffing, four CNAs not enough to care for residents. During an interview on 6/26/23 at 10:15 AM, CNA scheduler (SCHED) explained the NOC schedules are for an average census 100 in building. SCHED stated this required six to seven CNAs to handle the acuity. SCHED confirmed that the schedules that requested which had 4 CNAs was not enough. SCHED stated evening and NOC shifts are the hardest to staff, getting better.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure that Certified Nursing Aides (CNAs) are able to demonstrate competency in skills to follow the residents plan of care to meet their needs. This failure resulted in dependent residents not to receive nursing interventions to ensure their plan of care was implemented. Findings: A review of a Certified Nursing Assistant (CNA) job description undated, indicated they provide routine daily nursing care and services in accordance with the plan of care of each resident based on established nursing care procedures and the direction of a supervisor. Ensures residents needs are maintained with the highest degree of dignity. Promptly answers resident call lights and provides appropriate responses and requests. Performs comprehensive resident care duties including but not limited to bathing, vital signs, changing linens, properly positioning residents and giving AM and PM care. Reports the following in accordance with established facility procedures and regulatory standards resident grievances, complaints and allegations of abuse. Reviews care plans daily to determine if changes in resident daily routine. Activities of Daily Living care was not provided for dependent residents for Resident 33, 29, 23, 302 did not receive scheduled showers; and Residents 32 and 64 had long, jagged fingernails for months. A review of the resident concern and grievance log, indicated from 2/2-6/10/23, seven out of 11 resident complaints listed the concern was related to nursing and Certified Nursing Assistant (CNA) care. During a concurrent observation and interview on 06/22/23 at 3:50 PM, Resident 63 remembered the complaint he had about CNA E back on 2/1/23. Resident 63 was in a special wheelchair due to being contracted in both arms and legs. Resident 63 stated she was rough, and threw him in his bed and took my call light device so I could not call for help. Resident 63 stated NOC shift staff are all registry and do not have time to care for residents. Resident 26 confirmed staff do not come timely for call lights, often he has waited more than an hour when he was wet. Resident 26 stated he calls for assistance for Resident 63 who has to yell out for help. Resident 63 stated has to wait for more than an hour and both room mates stated this makes them angry. Resident 63 stated CNAs on this last Monday and Tuesday told him they were working doubles and staff talk about multiple admissions that come in which takes up their time. A review of a resident grievance/complaint form dated 2/17/23, indicated a Physical Therapy Assistant (PTA) documented that Resident 74 reported CNA C seems to be upset for caring for him and that his needs are not being met by this CNA. Under actions indicated room change or CNA change. On the concern/grievance log on 2/17/23 indicated the SSD was to follow-up and resolution was a room move for resident. A review of a resident grievance/complaint form dated 5/24/23, PTA documented that Resident 86 stated that CNA A does not attend to her when needed. CNA A does not assist Resident 86 when she wants to use the bathroom, get changed or go to bed. Resident 86 stated CNA A has outbursts when she asked her for assistance and helps her only when she has time not when Resident 86 requested help. On the concern/grievance log dated 5/24/23, the assigned staff member to follow-up was Director of Nursing (DON) and SSD, the resolution was CNA A was removed from Resident 86's hallway. A review of the resident council meetings minutes indicated: On 10/27/22, dietary services spoke to the resident about consistency on time that the meal carts come out from the kitchen. Two out of eights residents stated they are not offered supplies for mouth hygiene. Five out of the eight residents stated they have not had a shower in a long time. On 11/20/22, dietary services explained to the residents how he was fixing the snacks problem, to ensure they are always available. A resident on Hall 2 stated she had waited over one hour today for personal care and was wet as a result. A resident stated residents that need assistance in the dining room are not receiving help then staff take their trays away. On 12/28/22, a resident stated she was having to wait a long time for her call light to be answered and continued, unresolved. A review of a the nursing department response indicated remind Certified Nursing Assistants (CNAs) to answer call lights in a timely manner, this was the same response for 11/20/22. During an interview on 6/22/23 at 10:45 AM, Treatment Nurse (Tx RN) stated CNAs do not perform very good job with caring for residents with catheters or colostomies in general. Tx RN stated some have competencies they must do but some CNAs are slacking in other areas. Tx RN stated that she has gone multiple times to department heads regarding some CNAs, but nothing changes. Tx RN stated she has talked to the DSD about specific CNAs and the answer was to move the CNA to a different section, or to move the resident to another room. Tx RN stated she has talked to the DON and Administrator too, same answer. During an interview on 6/23/23 at 9:34 AM, Director of Staff Development (DSD) confirmed, Yes, we need to get back to the basics of before Covid19. DSD states she educated the CNAS to tell the nurse on the hall, maybe we need another time scheduled for resident showers if refused and keep updating the nurses if they refuse. DSD confirmed residents do not get their faces and hands washed before breakfast. During a concurrent interview and record review on 6/23/23 at 10:45 AM, DSD confirmed there was no abuse training provided to the facility staff in May. DSD confirmed there were no skill check audits of CNA skills available to view prior to her starting about six week ago. DSD stated she recently did skill checks on all CNAs to identify areas of needed improvement. Reviewed the last year of CNA inservices provided and the DSD confirmed some of the sign in sheets did not reflect the entire CNA staff. During an interview on 6/26/23 at 10 AM, Director of Nursing (DON) stated the DSD position has not been consistently filled over the past year. DON stated the previous one was not consistent in staff competencies and education.

CONCERN (E)

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

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected multiple residents

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Based on interview and record review the facility failed to ensure performance reviews for four out of six Certified Nursing Assistants (CNA A, B ,C and D) were completed every 12 months. This had the potential for direct care staff not to provide quality of care and meet the needs of the residents. Findings: During a concurrent interview and employee file review on 6/23/23 11 AM, the Director of Staff Development (DSD) confirmed there were no annuals performance reviews completed for: 1. CNA A, Date Of Hire (DOH) 3/18/22. 2. CNA B, DOH 12/1/21. 3. CNA C, DOH 9/29/2009. 4. CNA D, DOH 7/5/17, the last completed annual evaluation was on 7/12/2020. During an interview on 6/22/23 2:45 PM, the Administrator (ADMIN) confirmed no annual reviews had been done for CNAs for some time. ADMIN confirmed they currently do not have a policy but verified with management that the expectation was to complete them annually.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and facility policy and procedure review, the facility failed to ensure the menu was followed when: 1. The procedure to puree foods was not followed for eight of eight residents, 2. Correct portion sizes were not followed and 3. Gravy was not added per the menu. This failure had the potential to not meet the resident's nutritional needs. Findings: 1. During a review of the facility's record, Corporate recipe-number 7277; Entrée-Beef, undated, indicated for pureed beef measure the desired number of servings into the food processor. Blend until smooth. Add liquid if product needs thinning. Add commercial thickener (powder substance that thickens the pureed food) if product needs thickening. Liquid and thickener measurements are approximate and slightly more or less may be required to achieve desired pureed consistency. During an observation and interview on 6/21/2023 at 11:12 AM, in the kitchen, with [NAME] 1, [NAME] 1 stated he was preparing pureed meatloaf for eight residents. [NAME] 1 cut the meatloaf into portions and weighed out eight 4-ounce portions and placed each one in the blender. [NAME] 1 blended the meat and added an unmeasured quantity of beef broth from a small steamtable pan (6 7/8 inches by 6 ¼ inches) that was ¾ full. [NAME] 1 continued to blend the meat and stated it should be the consistency of ice-cream. While the meat was blending, [NAME] 1 added an unmeasured quantity of beef broth to the meat a total of three times and stated he was looking for pudding consistency. [NAME] 1 then added and unmeasured quantity of thickener a total of three times. [NAME] 1 placed the puree meat in a pan for lunch meal service. During an observation and interview on 6/21/2023 at 11:29 AM, in the kitchen, [NAME] 1 used a #8 scoop to place 12 portions of carrots into the blender then started to blend the carrots. [NAME] 1 had liquid which he stated was vegetable broth in a small steamtable pan (6 7/8 inches by 6 ¼ inches) that was ¾ full. [NAME] 1 used a 2-ounce ladle to add 4 ladles of vegetable broth to the carrots in the blender. [NAME] 1 looked at the consistency and added 4 more ladles of vegetable broth and continued to blend the carrots. [NAME] 1 then added an unmeasured quantity of vegetable broth by pouring the broth directly from the steamtable pan into the blender a total of three times. [NAME] stated it should be the consistency of ice-cream and hold it shape and not be runny. [NAME] 1 stated he might need to add thickener. [NAME] 1 then added an unmeasured quantity of thickener a total of three times. [NAME] 1 lined a pan with an oven liner and placed the pureed carrots in the pan for lunch meal service. During a test tray from the facility kitchen on 6/21/2023 at 1:03 PM, Certified Dietary Manager (CDM) and three surveyors tested regular and pureed meatloaf and carrots. The three surveyors agreed the pureed beef had a very strong seasoning taste which was different from the regular meatloaf. CDM agreed the pureed meatloaf had a strong seasoning taste. CDM stated the beef broth base used to puree the meat may have been too strong. During an interview on 6/21/2023 at 2:45 PM with CDM, the CDM confirmed the food should be pureed first then add the minimum amount of liquid then add thickener if needed. 2. Review of the facility's policy and procedure titled, Menus, dated 9/2017, indicated menus will be served as written, unless substitution is provided in response to preference, unavailability of an item, or a special meal. Review of the facility's record titled, Bridgeview Post-Acute Week -At-A-Glance; Week 1, indicated on 6/21/2023 the lunch meal consisted of homestyle meatloaf with ketchup glaze, honey roasted carrots, duchess mashed potatoes, dinner roll, and a lemon bar. Review of the facility's record titled, Bridgeview Post-Acute Diet Guide Sheet. indicated in ounces, the expected amount of meatloaf a resident should receive depending on their diet portions. Regular portions were to receive 4 ounces of meatloaf, large portions 6 ounces of meat loaf and small portions 3 ounces of meatloaf. The diet guide sheet indicated the small portion meal was to receive 3/8 cup (equivalent to 2.6 ounces) of honey roasted carrots and 3/8 cup of duchess mashed potatoes. During an observation on 6/21/2023 at 11:49 AM in the kitchen, [NAME] 1 was observed cutting all the meatloaf in the pan into 4-ounce portions for lunch service. During an observation on 6/21/2023 at 11:56 AM in the kitchen, one portion of the sliced meatloaf was weighed on the food scale and weighed 4 ounces. During an observation on 6/21/2023 at 12:18 PM in the kitchen, during the lunch meal tray line, Resident # 40's meal ticket indicated Resident # 40 was expected to receive large portions with small portions of starch (duchess mashed potatoes). Resident # 40's tray had a 4-ounce portion of meatloaf not the 6-ounces that were expected. Resident # 40 received a regular portion of starch not the small portions that were expected. During an observation on 6/21/2023 at 12:21 PM in the kitchen, during lunch tray line, Resident # 51's meal ticket indicated Resident # 51 was expected to receive large portions. Resident # 51's tray had a 4-ounce portion of meatloaf not the 6 ounces that were expected. During an observation on 6/21/2023 at 12:24 PM in the kitchen, during lunch tray line, Resident # 3's meal ticket indicated Resident # 3 was expected to receive small portions. The meal ticket indicated Resident # 3 was expected to receive 3/8 cup of duchess potatoes and honey roasted carrots. Resident # 3 received a regular portion (1/2 cup) of carrots and regular portion (1/2 cup) of duchess mashed potatoes. During an interview on 6/21/2023 at 12:25 PM with [NAME] 1, [NAME] 1 was asked how he measured 3/8 cup, [NAME] 1 stated he used a 2-ounce scoop. During an interview on 6/21/2023 at 1:19 PM with the CDM confirmed large portions were not provided for Resident # 40 and # 51 and Resident # 3 did not receive small portions. CDM confirmed the kitchen did not have a food scoop that was equivalent to 3/8 cup portion size. CDM agreed the portion of food was incorrect on Resident #3 and Resident # 40's trays. 3. Review of the facility's policy and procedure titled, Menus, dated 9/2017, indicated menus will be served as written, unless substitution is provided in response to preference, unavailability of an item, or a special meal. Review of the facility's record titled, Bridgeview Post-Acute Diet Guide Sheet. indicated, the, lacto-ovo vegetarian menu was expected to receive a veggie beef pepper patty with vegetable gravy. During an observation on 6/21/2023 at 12:21 PM in the kitchen, during lunch meal tray line, Resident # 51 was on a regular dysphagia advanced diet. Resident # 51's meal ticket indicated Resident # 51's meal tray was expected to receive 2 ounces of gravy. Resident # 51's meal tray did not have gravy. During an observation on 6/21/2023 at 12:21 PM in the kitchen, during lunch meal tray line, Resident # 3 was on lacto-ovo vegetarian advanced dysphagia diet. Resident # 3's meal ticket indicated Resident # 3 meal tray was expected to receive a veggie beef pepper patty with 2 ounces of vegetable gravy. Resident # 3's veggie beef pepper patty did not have gravy. During an interview on 6/21/2023 at 12:25 PM with [NAME] 1, [NAME] 1 stated he should have made the vegetable gravy. During an interview on 6/21/2023 at 1:19 PM with CDM confirmed Residents # 51 and # 3 did not receive gravy as indicated on the menu.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and record review the facility failed to ensure food safety and sanitation guidelines were followed when: 1. The ice machine was not in sanitary condition, 2. Time Temperature Control for Safety Foods (TCS) (food that requires time and temperature to limit the growth of illness causing bacteria) were not handled safely, 3. Food was not stored safely, 4. Food preparation equipment was not cleaned or air dried, 5. Nonfood contact surfaces were not clean, and 6. One food preparation sink and one steamer did not have an air gap. These failures had the potential to cause food borne illnesses in a medically vulnerable population of 99 who received food prepared in the kitchen. Findings: 1. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, (A) Equipment, food-contact surfaces and utensils shall be clean to sight and touch. During a review of the facility's policy and procedure titled, Ice, dated 9/2017, indicated, ice will be prepared and distributed in a safe and sanitary manner. During a concurrent observation and interview on 6/20/2023 at 9:40 AM with Maintenance Assistant (MA), in the kitchen, the ice machine was observed to have black residue on the inside top and sides around the chute. MA stated he was getting ready to clean the ice machine which was last cleaned on 5/26/2023. MA stated he was directed by the administration to increase the cleaning of the ice machine to twice a month instead of monthly. MA stated the black residue is there every time he has cleaned the ice machine. MA stated he followed the ice machine guidelines per the owner's manual which was observed to be open and on the counter. During a concurrent observation and interview on 6/20/2023 at 9:45 AM with Director of Maintenance (DM) in the kitchen, DM wiped the black residue inside the ice machine with a clean paper towel. The black residue was observed on the paper towel. DM confirmed the ice machine should not have black residue. 2. According to the USDA Food Code 2022 Section 3-501.14 Cooling, (A) Cooked TCS food (food that requires time and temperature controls to limit the growth of illness causing bacteria) shall be cooled: (1) Within 2 hours from 57 degrees Celsius(C)[135 degrees Fahrenheit(F)] to 21 degrees C (70 degrees F); and (2) Within a total of 6 hours from 57 degrees C (135 degrees F) to 5 degrees C (41 degrees F) or less. During a review of the facility's policy and procedure titled, Food: Preparation, dated 9/2017, indicated, prepared hot food items that are not intended for immediate service will be cooled using the following guidelines: 1. Temperature for TCS foods will be recorded at time of service, and monitored periodically during meal service periods. 2. Prepared hot foods items that are not intended for immediate service will be cooled using the following guidelines: a. TCS foods will be cooled from 135 degrees Fahrenheit (F) to 70 degrees F within 2 hours. b. TCS foods will be cooled from 70 degrees F to 41 degrees F within 4 hours. c. Total cooling time cannot exceed 6 hours. The clock starts at 135 degrees F. During a concurrent observation and interview on the initial kitchen tour on 6/20/2023 at 8:59 AM with the Dietary Supervisor (DS), a container of macaroni salad made by the facility was in the refrigerator. DS stated it was made on 6/19/2023 and served for lunch on 6/19/2023. DS stated the pasta was cooked then cooled and mayonnaise and hard-boiled eggs were then added. During a concurrent observation and interview on 6/22/2023 at 9:31 AM with Certified Dietary Manager (CDM) in the dietary office, the cool down log (record of temperatures kept after food is cooked to make sure it is cooled down in a specific amount of time to limit the growth of illness causing bacteria) was blank for the month of June 2023. CDM stated, we try not to use the cool down log because the kitchen staff cook and serve all the food so there are no leftovers. CDM agreed chicken, potato, tuna, and macaroni salad should all be cooled down appropriately and should be monitored and recorded on the cool down log. CDM agreed and confirmed the macaroni salad made in the facility on 6/19/2023 and observed in the refrigerator on 6/20/2023 should have been monitored and recorded on the cool down log but was not. 3. During a review of the facility's policy and procedure titled, Food Storage: Cold foods, dated 4/2018, indicated, all foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. During the initial tour of the kitchen on 6/20/2023 at 8:59 AM with DS, a square plastic container of jelly was observed in the refrigerator. The lid to the plastic container was warped which prevented the lid from securely covering the food. DM confirmed the lid did not cover the food and should be replaced. 4. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils (C) Nonfood- contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. During the review of the facility's policy and procedure titled, Equipment, dated 9/2017, indicated, all food service equipment will be clean, sanitary, and in proper working order. All food contact equipment will be cleaned and sanitized after every use. During a review of the facility's policy and procedure titled, Manual Ware washing, dated 9/2017, indicated, all service ware and cookware will be air dried prior to storage. During a concurrent observation and interview on 6/21/2023 at 11:44 AM with CDM, a blender stored with the lid on was observed on the clean equipment storage rack. The blender was stored wet with dried food debris on the inside of the blender and lid. CDM confirmed the blender was stored wet and not clean. 5. According to the USDA Food Code 2022 Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-contact Surfaces, and Utensils (C) Nonfood- contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue and other debris. During the review of the facility's policy and procedure titled, Equipment, dated 9/2017, indicated, all food service equipment will be clean, sanitary, and in proper working order. All non- food contact equipment will be clean and free of debris. During the initial tour of the kitchen on 6/20/2023 at 8:59 AM with CDM, an observation and concurrent interview was conducted. Gray bins used to store forks and spoons were not clean. A bin used to store clean food preparation utensils was not clean. CDM agreed all observed storage bins were not clean. During a concurrent observation and interview on 6/20/2023 at 3:30 PM with CDM, five dish racks were observed with black residue. CDM confirmed the dish racks were not clean and needed to be replaced. CDM stated he had put in a request to replace the dish racks at the beginning of the year via email but was unable to provide any documentation. 6. According to the USDA Food Code 2022 Section 5-202.13 Backflow Prevention, Air Gap (an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment) shall be at least twice the diameter of the water supply inlet and may not be less than one inch. According to the FDA Food Code Annex 2022: 5-402.11 Backflow Prevention. Improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in the contamination of food, utensils, equipment, or other food-contact surfaces. During an observation on the initial tour of the kitchen on 6/20/2023 at 8:59 AM, a food preparation sink did not have an air gap. During an interview on 6/21/2023 at 10:06 AM with DM, confirmed the food preparation sink did not have an air gap. a. During an observation on 6/21/2023 at 11:56 AM, the steamer (a devised used to steam food) in the kitchen had a long black pipe that rested in the drain. The steamer pipe did not have an air gap. During an interview on 6/21/2023 at 4:00 PM with DM, confirmed the steamer did not have an air gap.

CONCERN (F)

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

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to ensure an effective Quality Assessment and performance Improvement (QAPI) plan was in place for identifying and responding to resident care concerns with a good faith effort, by implementing, monitoring, and evaluating action plans for weight loss, pressure ulcers, staffing and competency, and abuse. This failure had the potential to affect how the facility ensures care and services are delivered meet accepted standards of quality, identify problems and opportunities for improvement, and ensure progress toward correction or improvement was achieved and sustained. Findings: A review of a policy titled, Quality Assurance and Performance Improvement (QAPI) Program - Governance and Leadership, with a revised date of March 2020, indicated, The administrator . is ultimately responsible for the QAPI program, and for interpreting its results and findings to the governing body. The document indicated that the responsibilities of the QAPI committee included: identify, evaluate, monitor, and improve facility systems and processes that support the delivery of care and services . During a concurrent interview and record review on 06/26/2023 at 12:43 PM with Administrator (ADMIN), she stated that weight loss, pressure ulcers, staffing and competency, and abuse were not assessed under QAPI, and the facility did not have a plan to correct the areas identified during the survey. Upon record review of the QAPI plan book, there was not a plan in place to develop a plan of correction, which was confirmed by ADMIN.

Jun 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 record review the facility failed to ensure the responsible party (RP, medical decision maker) was informed of a change in a plan of care for Resident 1 when a psychotropic (medication for mood/behavior disorders) before the medication was administered. This had the potential for Resident 1 to be at risk for an unnecessary medication and falls. Findings: A review of a facility policy titled Psychotherapeutic Informed Consent-California undated, indicated residents have the right to be free from psychotherapeutic drugs used for physical discipline, staff convenience and a chemical restraint. Residents have the right to be informed of their medical care and treatment, including risks and benefits. Informed consent shall be reviewed by the physician with the resident or RP. Prior to administering the first dose of the psychotherapeutic medication the nursing staff will verify in the clinical record the facility obtained an informed consent. The medication order cannot be administered until informed consent is obtained by the physician. A review of Resident 1's admission records indicated she was readmitted to the facility on [DATE] with diagnoses which included fracture of left leg, bipolar disorder (mood disorder), depression, anxiety, and post traumatic stress disorder (PTSD, mental health disorder). Resident 1 was unable to make health care decisions for herself. A review of a hospital Discharge summary dated [DATE], indicated Resident 1 was transferred back to a skilled nursing facility, and under discharged medications an order for lorazepam (Ativan, anxiety medication) 0.5 milligrams (mg) one tablet every 12 hours. A review of Resident 1's Interdisciplinary Team (IDT, group of various medical staff that discuss resident plan of care) Psychotherapeutic review dated 8/23/22 at 5:46 pm, indicated the psychotropic medication use of Seroquel (antipsychotic), Wellbutrin (depression), recommended continued use, Ativan (lorazepam) to be discontinued 8/30/22. A review of Resident 1's physician orders dated 9/29/22, lorazepam 0.5 mg one tablet by mouth every 12 hours related to anxiety disorder. A review of Resident 1's Medication Administration Record for September and October 2022, indicated she received lorazepam twice a day from 9/30-10/10/22, 11 days. A review of Resident 1's Informed Consent of Psychotherapeutic medications indicated the physician did not sign until 10/11/22, and licensed nurses did not verify informed consent was given to RP until 10/7/22. During an interview on 6/7/23 at 11:10 am, the Director of Nursing confirmed the informed consent was not obtained before administering the lorazepam and their facility informed consent policy was not followed.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure Resident 1 had a behavioral health evaluation and services to meet Resident 1's psychiatric behavioral needs. This had the potential for Resident 1 to be at risk for unnecessary psychotropic medications and a decline in their physical, emotional, and psychosocial well being. Findings: A review of a facility policy titled Antipsychotic Medication Use revised December 2016, indicated they may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. They will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. They will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. The interdisciplinary team will complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks to consider whether or not the medication can be reduced, tapered, or discontinued. A review of Resident 1's admission records indicated she was readmitted to the facility on [DATE] with diagnoses which included fracture of left leg, bipolar disorder (mood disorder), depression, anxiety, and post traumatic stress disorder (PTSD, mental health disorder). Resident 1 was unable to make health care decisions for herself. A review of the preadmission screening and resident review (PASRR, identifies residents with serious mental illness and determines needs for third party specialized services) dated on first admission 8/8/22 and readmission on [DATE], indicated Resident 1 triggered for a Level II assessment which helps determine placement and specialized services. The facility was notified that the Level II was unable to be performed by the third party. A review of a trauma assessment tool dated 9/29/22, indicated Resident 1 had experienced a trauma related event that gave them nightmares, thought about it when they did not want to, tried hard not to think about it and avoided situations that may remind them of the events. A review of Resident 1's Interdisciplinary Team (IDT, group of various medical staff that discuss resident plan of care) Psychotherapeutic review dated 8/23/22 at 5:46 pm, indicated the psychotropic medication use of Seroquel (antipsychotic), Wellbutrin (depression), recommended continued use, Ativan (lorazepam) to be discontinued 8/30/22. There was no documentation that the IDT determined Resident 1 had a referral for a psychiatric or telehealth evaluation. This was the only IDT meeting about Resident 1's psychotropic and behavior management for the entire admission. A review of Resident 1's physician order summaries from admission on [DATE] through her discharge 12/15/22, indicated Resident 1 was prescribed: -Lorazepam 0.5 milligrams (mg) one tablet by mouth every 12 hours as needed related to anxiety disorder, started 9/22/22, and discontinued 9/29/22, -Lorazepam 0.5 mg one tablet by mouth every 12 hours related to anxiety disorder, dated 9/29/22 and discontinued 10/10/22. -Seroquel (antipsychotic to treat mood disorder) 300 mg one table at bedtime for bipolar disorder dated 8/8/22. -Sertraline (depression) 50 mg one tablet a day for major depressive disorder dated 8/8/22 -Bupropion (depression) 100 mg twice a day related to major depressive disorder dated 8/8/22. -Trazodone (depression) 100 mg one tablet at bedtime for insomnia dated 8/8/22. A review of Resident 1's record, there were no mental health referrals or evaluations found in her record. During an interview on 6/7/23 at 11:20 am, the Director of Nursing (DON) confirmed Resident 1's PASRR level II evaluation did not occur due to the third party declining. DON stated during Resident 1's admission stay, they did not have IDT psychotherapeutic reviews. DON stated the facility has not had a contract with psychiatrist or psychiatric telehealth (via video chatting) for at least two years. DON confirmed Resident 1 did not receive any out side mental health evaluation or support and could have benefited from this service due to her multiple diagnoses and psychotropic medications.

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

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 and record review the facility failed to ensure Resident 1 was free from an unnecessary psychotropic medication when there was no clinical justification or consent to give the medication. This resulted in Resident 1 to receive an unnecessary psychotropic medication which put her at risk for adverse side effects and falls. Findings: A review of a facility policy titled Antipsychotic Medication Use revised December 2016, indicated they may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. They will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. The Attending Physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others. They will identify, evaluate and document, with input from other disciplines and consultants as needed, symptoms that may warrant the use of antipsychotic medications. The interdisciplinary team will complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate; or re-evaluate the use of the antipsychotic medication at the time of admission and/or within two weeks to consider whether or not the medication can be reduced, tapered, or discontinued. A review of Resident 1's admission records indicated she was readmitted to the facility on [DATE] with diagnoses which included fracture of left leg, bipolar disorder (mood disorder), major depression, anxiety, and post traumatic stress disorder (PTSD, mental health disorder). Resident 1 was unable to make health care decisions for herself. A review of Resident 1's Interdisciplinary Team (IDT, group of various medical staff that discuss resident plan of care) Psychotherapeutic review dated 8/23/22 at 5:46 pm, indicated the psychotropic medication use of Seroquel (antipsychotic), Wellbutrin (depression), recommended continued use, Ativan (lorazepam) to be discontinued 8/30/22. This was the only IDT meeting about Resident 1's psychotropic and behavior management for the entire admission. A review of a Psychotropic Medication Log (tracks daily behaviors) for the year of 2022, indicated Resident 1 was being assessed for anxiety with no exhibited behavior indicated. There was no anxiety documented for August and September. The log indicated Resident 1 had six anxious behaviors documented for October. A review of a change of condition note dated 9/24/22 at 12:59 am, indicated Resident 1 had a fall that resulted in a left hip surgery and hospitalization. Resident 1 was discharged back to the skilled nursing facility on 9/29/22. A review of an nursing admission assessment dated [DATE] at 2:21 pm, indicated under mental status lethargic. A review of a hospital Discharge summary dated [DATE], indicated Resident 1 was transferred back to a skilled nursing facility, and under discharged medications an order for lorezepam (Ativan, anxiety medication) 0.5 milligrams (mg) one tablet every 12 hours. A review of the physician orders for Resident 1 indicated: -Lorazepam 0.5 milligrams (mg) one tablet by mouth every 12 hours as needed related to anxiety disorder, started 9/22/22, and discontinued 9/29/22. -Lorazepam 0.5 mg one tablet by mouth every 12 hours, related to anxiety disorder, dated 9/29/22 and discontinued 10/10/22. A review of Resident 1's Informed Consent of Psychotherapeutic medications indicated the physician did not sign until 10/11/22, and licensed nurses did not verify informed consent was given to RP until 10/7/22. A review of a physician note dated 10/4/22, Medical Director (MD) indicated Resident 1 denied anxiety, sleep problems, and suicidal ideations. The medical reconciliation list did not include lorazepam, it did include Wellbutrin, Seroquel, Trazodone (sedative), and Zoloft (PTSD). A review of Resident 1's Medication Administration Record for September and October 2022, indicated she an as needed lorazepam on 9/22/22, and twice a day from 9/30-10/10/22, 11 days. A review of an electronic medication administration note dated 9/22/22 at 4:45 pm, indicated Resident 1 was administered 0.5 mg lorazepam as needed with no reason or behavior documented. During an interview on 6/6/23 at 10:10 am, Pharmacy Consultant (Pharm D) stated IDT should be monitoring and evaluating residents on psychotropics along with physician to evaluat the effectiveness and justification for these medications. Pharm D confirmed the order for Ativan should have had a specific behavior exhibited to be measurable not just state anxiety. Pharm D confirmed the four other psychotropics Resident 1 prescribed can also treat anxiety. During an interview on 6/7/23 at 11:20 am, the Director of Nursing (DON) stated during Resident 1's admission stay, they did not have IDT psychotherapeutic reviews. DON confirmed the IDT committee discontinued the lorazepam on 8/30/33. DON stated there were no IDT meeting or notes found in the record that indicated the clinical justification and anxiety behavior for Resident 1 to restart the lorazepam on 9/22/22 and 9/29/22. DON confirmed Resident 1 had orders for four other psychtropics not including the lorazepam.

Jun 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment when the tile in two shower rooms was in disrepair, and there was dirty, standing water on the floor of one of the shower rooms. This failure had the potential to promote the growth and spread of disease-causing germs, and the appearance of the tile could have caused the residents to experience anxiety, both of which had the potential to threaten the residents' well-being. Findings: During a concurrent observation and interview, on 5/24/23, at 11:47 am, the Administrator confirmed the appearance of one of the shower rooms located closest to the front lobby. The floor of the shower had a large tan stain and blackened grout, and a circular area beneath the tap fixture was worn and a yellow color. These stains resulted because a white coating that had been applied over the existing tile at some point in the past had worn off. During a concurrent observation and interview, on 5/24/23, at 12:38 am, Certified Nursing Assistant (CNA) A confirmed the condition of a second shower near room [ROOM NUMBER]. There was a large tan-colored area on the floor of the shower with a pool of dirty standing water. A long-handled floor squeegee (a flat rubber blade attached to a pole) and two scrub brushes were stored across from the shower stall. CNA A confirmed there was a white coating applied over the existing tile and it had worn off, and there was standing water on the floor and the squeegee was used to push the water down the drain.

May 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, this requirement was not met when Resident 2 brought a firearm to the facility and the facility did not follow its stated policy. This resulted in placing residents in a potentially dangerous environment or causing loss of life. FINDINGS A review of the facility's policy titled, Firearms and Other Weapons, dated April 2007, indicated as follows: 1. Our facility prohibits any employee, resident, visitor, vendor, or any other individual from possessing firearms or other weapons designed to do bodily harm .while on our facility's premises. 2. Individuals, other than law enforcement officials, who are licensed to carry weapons must leave their weapons at the administrative office or with the security officer before entering resident care areas 3. Signage is posted throughout the building relative to our facility's policies governing the possession of firearms or other weapons while in or on our facility's premises. 4. An employee who suspects an individual of carrying a weapon should not confront the individual but should immediately contact the security officer or supervisor and inform him/her of the suspicions. 5. Violations of this policy will result in immediate termination of employment, discharge from the facility, denial of visitation privileges . In an interview on 5/3/23 at 11:50 AM, Director of Nursing (DON A) stated that on 4/8/23, a CNA had walked into Resident 2's room and saw him pull a gun out of a caddy for his computer tablet. DON A indicated that the staff were able to convince the resident to turn over the weapon to them. In an interview on 5/3/23 at 1:20 PM, Licensed Vocational Nurse (LVN B) stated that she was attending to her residents on 4/8/23 and a housekeeper alerted her to a gun. CNA B stated that she got help from a nurse and a CNA at the facility and they convinced the resident to hand over the gun. In an interview on 5/3/23 at 1:50 PM, DON A presented the facility's policy on firearms after uncertainty if there was a policy. DON A was able to locate the policy but stated that there had not been an opportunity to test it since this situation had not yet arisen. In concurrent record review of the facility's policy, it was [NAME] to DON A's attention that the facility had no signage regarding firearms per its policy, which she acknowledged, and that staff had intervened and taken the firearm from the resident contrary to current stated policy. Other policy discrepancies existed such as not discharging resident from the facility, which DON A stated needed to be reviewed for appropriateness now that this type of event has occurred. DON A stated that it was an opportunity for the facility to review its firearms policy for accuracy and practicality.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, this requirement was not met when 8 of 22 sampled residents expressed that their food was too tough, too cold, or unpalatable, and 8 of 22 sampled residents stated the meals were frequently delivered late. This resulted in the potential for weight loss, illness, choking, and deterred from residents' experience of a 'home like' meal. Findings: A review of the facility's record titled, Mealtimes, [undated, presented as current policy by Director of Nursing (DON A)], indicated: Meals will START [facility's added emphasis] being served within this time frame Lunch: 11:50 am. A review of the facility's record titled Menu dated 5/3/23, indicated one of the day's lunch choices was Herb Crusted Pork Chop. In an interview on 4/19/23 at 11:22 AM, Resident 1 stated, The Food is lousy. He did not elaborate. In an interview with Resident 2 on 5/3/23 at 12:07 PM, it was concurrently observed that his lunch had not yet arrived. Resident 2 stated, You're never sure what you're going to get or what time it will come. In an interview with Resident 3 at on 5/3/23 at 12:10 PM, it was concurrently observed that his lunch had not yet arrived. Resident 3 stated, Meals are slow. We're supposed to get fed at 12 for lunch, but we're lucky if they get it out by 1:15. In an interview with Resident 5 on 5/3/23 at 12:30 PM, it was concurrently observed that his lunch had not arrived. Resident 5 stated, Meals are slow. Especially lunch. They are not always served at the same time. Lunch is not here yet and it was supposed to be out at noon. In an interview on 5/3/23 at 12:33 PM, Resident 6 stated, Food times fluctuate. Lunch is supposed to be here by noon or 12:30, but it can be as late as 1:00. They take their time. In an interview on 5/3/23 at 12:50 PM, it was concurrently observed that resident 7's food had not yet arrived. Resident 7 stated, Lunch is late today. I would say it's late half the time. On 5/3/23 at 12:51 PM, lunch carts were observed being brought to the hall. In an interview on 5/3/23 at 12:52 PM, Resident 8's lunch was observed being brought to him. Resident 8 stated, Lunch is late a lot. I guess they don't have enough people back there. In an interview on 5/3/23 at 1:00 PM, Resident 9 stated that she was the facility's current Resident Council President (an appointee by all residents to represent their concerns to administration). Resident 9 stated, Usually lunch comes around 12, but they've been coming out anytime from 12:30 to after 1:00. Residents are complaining to me all the time about late meals. It was concurrently observed that Resident 9 had what appeared to be an entire uneaten pork chop with a small piece unsuccessfully cut from the side. The pork did not appear to be crusted. Resident 9 stated, I can't eat this. It's too tough. In an observation and interview on 5/3/23 at 1:03 PM, Resident 10 had a large cut of light-colored meat on her plate that appeared to be an uneaten pork chop. The meat did not appear to be crusted and had a brown sear mark on it. Resident 10 also had pink liquid in a plastic cup that she stated, was supposed to be cranberry juice. Resident 10 stated that she could not identify what the food was on her plate, stating, I can't cut this, whatever it is. Resident 10 was observed using her thumb on the opposite hand to assist her with pressing her fork into the meat. She was observed to be unsuccessful in cutting it. Resident 10 stated she was unhappy about the pink liquid in her cup. This is supposed to be cranberry juice. I don't know if they're watering it down or what, but this is not what cranberry juice looks like. Resident 10 stated she was refusing the liquid and her lunch. In an interview on 5/3/23 at 1:06 PM, Resident 11 stated, These are not good meals. They are not tasty. I would not cook this kind of food at home. Resident 11's meat remained on her plate, uneaten. Resident 12 was admitted to the facility on [DATE] for conditions that included diabetes and gastroesophageal reflux (food and stomach contents coming up into the upper digestive tract). Resident 12 was observed to have multiple missing front teeth. She stated, I've been to this facility three times. This time I'm here for my stomach. Resident 12 speared a large piece of uneaten meat on her plate; it did not appear crusted, rather, seared. Resident 12 indicated an approximately 1 piece hanging from the side of the meat cut, which she demonstrated she could not cut free. I'm not eating this. I'm here for my stomach, and I'm not going to eat a meal I can't chew or digest. Resident 12 was also observed to have a large plastic cup filled with a Cheerios-type cereal. This was from my breakfast. I saved it as insurance in case lunch was bad. I'll have it for dinner. I stopped eating their cold, ' carton-ready' eggs that they make every day. They're cold and they're not palatable or warm. In an interview on 5/3/23 at 1:00 PM, Resident 12 stated, Usually lunch comes around noon, but they've been coming around anywhere from 12:30 to 1:00. Residents complain all the time to me about late meals. It was concurrently observed that Resident 12's meat from her lunch remained on her plate uneaten, with a small section on one side that appeared to be partially cut off. Resident 12 took her fork and knife into her hands and started demonstrating how difficult it was to cut the meat on her plate, and that she could not even pierce it with a fork. She stated, I can't eat this. It's too tough. Resident 12 further indicated that she has had so many issues with the facility's food that she now saves her tray slips and compares what is written to what she actually receives; most of the slips she had crossed through indicating substitutions that had been made for her without her request. For instance, on 4/30/23, the facility's slip indicated oven browned potatoes, which resident struck through and recorded peas, and no brown gravy was received. For dinner on 4/30/23, Resident 12 indicated she had not received the brown gravy on the slip. On 5/1/23, Resident 12's tray slip indicated, Margarine, 1 each. Resident 12 had crossed it out and written no margarine on tray. Similarly, on 5/11/23, resident 12 indicated she had not received Chocolate Cake with Peanut Butter Icing, Brown Gravy, or Savory Summer Soup. Resident 12 stated, My roommate was supposed to get chicken noodle soup and it never came, so I went to the kitchen to ask for it. Resident 12 pointed to what appeared to be a partially chewed piece of meat that she had spit back out on her plate. Resident 12 stated, Today, this is supposed to be a ' crusted pork chop.' It's not crusted, (no crust observed), but I can't eat it anyway, so that doesn't matter. Resident 12 further stated, Lunch was supposed to be at noon, but they just started feeding us now. In an interview on 5/3/23 at 1:35 PM, Resident 13 was observed to have an entire, untouched piece of meat on her lunch plate. I'm not going to even attempt to cut this. I tried to eat it. I don't know if anyone could eat this. Resident demonstrated how she could not push her fork into the meat. In an interview and concurrent observation on 5/3/23 at 1:36 PM, Resident 14 was observed to have an entire, uneaten piece of meat on his lunch plate. Resident 14 stated, I couldn't eat it. In an interview and concurrent observation on 5/3/23 at 1:45 PM, Resident 15 was observed to have a majority of a piece of meat on his plate, uneaten. Resident 15 stated. It's a pork chop. I couldn't eat it. In an interview on 5/3/23, Dietary Manager (DM C) indicated that he was employed by an outside dietary management company. DM C stated that published mealtimes were suggestions and when the tray line should start in the kitchen. DM C stated that meals were late that day because there was an issue with the calibration on the stoves. We knew something was wrong because the food wasn't cooking right. In an interview and concurrent record review on 5/3/23, DON A reviewed the meal schedule and stated, These are posted times for residents to see on the bulletin board, and that meals were expected to be delivered at those times, not started in the kitchen at those times. DON A further indicated that the company providing meals was new to the facility and having some growing pains.

Mar 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 clinical record review, the facility failed to ensure that one of three sampled residents' (Resident 1) care plan was reviewed and revised by the interdisciplinary team (IDT-professional disciplines that work together in the best interest of the resident) when Resident 1 had a significant change in condition which required oxygen for shortness of breath (SOB), increased insulin usage for elevated blood sugars (BS), and the holding of her heart medications due to low blood pressures (BP). This failure resulted in person-centered approaches not being identified and interventions not being implemented for Resident 1's change in condition which resulted in a hospital admission with the diagnose of sepsis (a body's extreme response to an infection and is a life-threatening medical emergency) and pneumonia. Findings: During a review of the facility's policy titled, Care Plans, Comprehensive Person-Centered dated March 2022, the policy indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition. During a review of the facility's policy titled, Change in a Resident's Condition or Status dated May 2017, the policy indicated, A significant change of condition is a major decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions c. Requires interdisciplinary review and/or revision to the care plan . A review of Resident 1's clinical record showed admission to the facility on [DATE], with diagnoses that included diabetes, atrial fibrillation (an irregular fast heart rhythm), heart failure and hypertension (high blood pressure). During a review of Resident 1's nursing progress notes Licensed Nurse (LN) C documented on 2/19/23 at 3:11 pm, Writer performed daily vitals on resident and came across resident's O2 [oxygen] sat [saturation in the blood] to be 83% [percent] while resident is sitting in bed in high fowler's [seated upright at a 90-degree angle] position. Resident had a PRN [as needed] order for Oxygen 2 L/min [Liters per minute] as needed for SOB. Writer went ahead and administered O2 2L/min via NC [Nasal Cannula, a tube that delivers oxygen to the nose] to resident and cont. to monitor resident. Writer reassessed resident in 30 min and resident's O2 Sat. was now 89%. Resident cont. to be on O2 therapy. Dr [primary physician] made aware. Communicated to oncoming staff to cont. to monitor and update MD if any other changes occur. During a concurrent interview and record review on 3/1/23 at 3:50 pm, with the Director of Nursing (DON), Resident 1's Care Plan and IDT notes were reviewed. The DON confirmed that there were no IDT notes or updates to Resident 1's care plan for her significant change of condition that occurred on 2/19/23, and there should have been. The DON indicated that because there was no SBAR (Situation-Background-Assessment-Recommendation, a tool used to communicate between members of the health care team about a patient's condition), documented in Resident 1's progress notes the IDT team was not alerted to her declining condition and therefore did not update the care plan with appropriate interventions.

CONCERN (D) 📢 Someone Reported This

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

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

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 interview and record review, the facility failed to recognize and monitor a significant change in condition and report this serious change to the physician for one of three sampled residents (Resident 1), when Resident 1 had shortness of breath (SOB) that required oxygen (O2), increased blood sugars (BS), and decreased blood pressures (BP). This failure resulted in Resident 1's condition deteriorating and required an emergency transfer to the acute care hospital where she was admitted to the Intensive Care Unit (ICU) in critical condition. Findings: During a review of the facility's policy titled, Change in a Resident's Condition or Status dated May 2017, the policy indicated the nurse will notify the resident's attending physician when there has been a significant change in the residents physical/emotional mental condition and when there is a need to alter the resident's medical treatment significantly. A significant change of condition is a major decline or improvement in the resident's status that will; not normally resolve itself without intervention by staff; Impacts more than one area of the resident's health status; Requires interdisciplinary review and/or revision to the care plan. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (Situation-Background-Assessment-Recommendation, a tool used to communicate between members of the health care team about a patient's condition) Communication Form. During a review of the facility's policy titled, cute Condition Changes dated March 2018, the policy indicated, Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician: for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse. b. Who has collected and organized pertinent information, including the resident/patient's current symptoms and status. The nurse and physician will discuss and evaluate the situation. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. During a review of the facility's policy titled, Oxygen Administration dated October 2010, the policy indicated, Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of cyanosis (i.e., blue tone to the skin and mucous membranes); 2. Signs or symptoms of hypoxia (i.e., rapid breathing, rapid pulse rate, restlessness, confusion) 4. Vital signs; 5. Lung sounds. A review of Resident 1's clinical record showed admission to the facility on [DATE], with diagnoses that included diabetes, atrial fibrillation (an irregular fast heart rhythm), heart failure and hypertension (high blood pressure). During a review of Resident 1's Quarterly Minimum Data Set (MDS, a complete clinical assessment of a resident) dated 1/20/23, the MDS indicated that, Resident 1 required extensive assistance with bed mobility, transfers, dressing and personal hygiene. Resident 1's Brief Interview for Mental Status's (BIMS, an assessment of cognition) score was 15, indicating her cognition was intact. A review of Resident 1's physician orders revealed that an order was written on 10/2/22 for oxygen 2 L/min (liters per minute) via NC (nasal cannula, a tube that delivers oxygen into a resident's nose) as needed (PRN), for SOB (shortness of breath). On 10/14/21 an order was written for amlodipine besylate (a medication to manage high blood pressure) tablet 5 milligram (mg), give 1 tablet by mouth one time a day for high blood pressure and to hold for SBP (systolic blood pressure, the top number in a blood pressure reading) less than 110 mm Hg (millimeters of mercury). On 11/23/22 an order was written for carvedilol (a medication to manage high blood pressure) tablet 6.25 mg, give 1 tablet by mouth two times a day for high blood pressure and hold for SBP less than 110. Hold for HR (heart rate) less than 50. During a review of Resident 1's Care Plan (CP) titled, Hypertension dated 10/7/22, the CP revealed an intervention to monitor blood pressure and notify her physician of any abnormal readings (Normal blood pressure is considered around 120/80). Resident 1's progress notes were reviewed. On 2/19/23 at 8:04 am, Licensed Nurse (LN) C documented, Resident O2 as low as 86% [percent] in high fowler's [sitting up in bed] position. Administered O2 2L/min PRN Cont. to monitor. On 2/19/23 at 3:11 pm, LN C documented, Writer performed daily vitals on resident and came across resident's O2 oxygen sat [saturation in the blood] to be 83% while resident is sitting in bed in high fowler's position. Resident had a PRN order for Oxygen 2 L/min as needed for SOB. Writer went ahead and administered O2 2L/min via NC to resident and cont. to monitor resident. Writer reassessed resident in 30 min and resident's O2 Sat. was now 89%. Resident cont. to be on O2 therapy. Dr [primary physician] made aware. Communicated to oncoming staff to cont. to monitor and update MD [Medical Doctor] if any other changes occur. There was no evidence of an SBAR on 2/19/23, and no nursing documentation of any assessments or monitoring of Resident 1's condition on 2/20 and 2/21/23. There was no documented evidence of how LN C communicated this information to the other nurses. A review of Resident 1's progress notes, dated 2/22/23 at 9:15 am, reflected that LN B had documented, Resident less active than usual, lethargic unable to get up from bed. Appetite decreased, nonproductive cough. NP [Nurse Practitioner] was in house and notified received order of labs ., chest xray and covid test all orders carried out. A review of Resident 1's progress notes, dated 2/23/23 at 10:38 am, reflected that LN B documented, Resident lethargic unable to get up from bed, appetite decreased, productive cough. Upon assessment resident's vital signs 98/59 [blood pressure], 18 [respirations], 97.2 [temperature], 76 [pulse], 92% [oxygen level] on 2 L, lethargic, productive cough crackled lungs sounds, send to ER [emergency room] for further evaluation. During a review of Resident 1's Medication Administration Record (MAR) for February 2023, the MAR revealed that Resident 1's BS were checked 4 times a day, before each meal and at bedtime. BS recordings from 2/1/23 to 2/17/23 had ranged from 128 mg/dL (milligram per deciliter) to 259 mg/dL. Resident 1's BS recordings during the week of 2/18/23 to 2/23/23 had increased, and ranged from 290 mg/dL to 400 mg/dL. According to the American Diabetes Association's web site; infection or other illness can make blood sugars rise. There was no evidence documented in Resident 1's clinical record that her physician was notified that her blood sugars were elevated. Resident 1's February 2023 MAR further revealed that her heart medications, carvedilol and amlodipine, were held due to a low SBP (top number was less than 110 mm/Hg), on 2/19/23 at 8:00 am for a BP of 99/40, on 2/20/23 at 8:00 am, but the B/P was not recorded, on 2/20/23 at 8:00 pm for a BP of 99/41, and on 2/21/23 at 8:00 am, for a BP of 101/50. There was no documented evidence in Resident 1's clinical record that her physician was notified of her low blood pressures and that the nurses had held her heart medications. During a review of Resident 1's emergency room Nurse Practitioner (ERNP) notes, the ERNP documented on 2/23/23 at 4:15 pm, Resident 1's diagnoses were acute respiratory failure with hypoxemia (low oxygen levels in the blood), severe sepsis (a body's extreme response to an infection and is a life-threatening medical emergency), acute metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood), hyponatremia (low sodium in the blood), and bacterial pneumonia (an infection of the lungs caused by bacteria). Resident 1 was admitted to the ICU in critical condition. During an interview on 3/1/23 at 1:30 pm, the Administrator (Admin) indicated that every morning the Interdisciplinary Team (IDT) would meet, and review residents' changes of condition based on the SBAR's that were charted in the electronic record Point Click Care (PCC). If the nurses did not do an SBAR they had no way of knowing that a change of condition had occurred. During an interview on 3/1/23 at 2:43 pm, LN C indicated Resident 1 was abnormally tired on 2/19/23 and not her usual self. LN C noticed that Resident 1 could not talk with her like she usually did so she took her oxygen saturations and saw that it was low. LN C stated she did not check Resident 1's lung sounds, and she should have. She stated that she did notify the MD about her needing the oxygen and he said to monitor her and report back to him if she gets worse. LN C did not recall whether or not she had told the MD about the high blood sugars or the low blood pressures and that she held the blood pressure medication that day. LN C confirmed that she did not chart a change of condition by doing an SBAR, and she should have. She indicated that she forgot. During an interview and record review on 3/1/23 at 3:50 pm, Resident 1's progress notes and February MARs were reviewed with the Director of Nursing (DON). The DON confirmed that on 2/19/23, Resident 1 had a significant change in her condition. The DON confirmed that Resident 1 required oxygen for shortness of breath, more insulin for higher blood sugars, and that her heart medications were held several times because her BP was too low. The DON confirmed that Resident 1's physician was not notified of these changes in her condition and he should have been. The DON confirmed that Resident 1 was not assessed and monitored by the nurses following the onset of those changes in her condition and that an SBAR had not been created. The DON stated, because the SBAR was not done we did not know she [Resident 1] was doing as badly as she was. During an interview on 3/2/23 at 10:30 am, the Nurse Practitioner (NP) confirmed that he had seen Resident 1 on 2/22/23, after being asked to see her by LN B. The NP indicated that he had ordered blood tests and a chest x-ray and an antibiotic. The NP confirmed that the staff had not informed him that Resident 1's blood sugars had been high, that her BP's were low and they were withholding her heart medications or that she had an oxygen saturation earlier in the week of 83%. The NP indicated that had he known all those details, he would have sent her to the hospital on the day he saw her. The NP confirmed that he did not get the full picture from the nurses of what was going on with Resident 1. During an interview on 3/2/23 at 1:01 pm, Resident 1's physician (MD) indicated that when the nurse called him on 2/19/23, about putting oxygen on Resident 1 due to low oxygen saturations, he confirmed he was not notified that she was also having low BPs and high BS. He indicated that if the nurse would have told him that she had held the heart medications due to low BPs and that she was having blood sugar readings of up to 400 mg/dl, he would have sent her to the ER on that day. The MD indicated health problems could worsen when he was not provided with, a full story of what was going on with a Resident. The MD indicated he relied on the nurses to give him the full picture of what was going on and in this case, that did not happen. During an interview on 3/7/23 at 2:00 pm, LN D confirmed that she took care of Resident 1 on 2/20/23 and was unaware that she had had a change of condition the day before. LN D recalled that Resident 1's BP was low and that her BS was higher than usual. LN D indicated she took Resident 1's vitals that morning, saw that she was on oxygen, not eating well and not looking well. LN D stated she assessed Resident 1's lungs, and they were not normal. LN D confirmed that she had not notified Resident 1's physician or documented her findings in Resident 1's medical record. LN D indicated that she reported her findings to the DON instead and thought, that was all I needed to do.

Nov 2022 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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to meet this requirement when one of three residents (Resident 1's) foley catheter (a tube that drains urine from the body) was observed to be crusted with discharge and accumulated debris, and was not cleaned per the facility's policy or the resident's care plan. This had the potential to cause UTI (urinary tract infection), pain, and a reduced quality of life for Resident 1. The resident had a history of UTI's. Findings: Resident 1 was admitted to the facility on [DATE] for brain injury, diabetes, chronic pain, and benign prostatic hyperplasia (an enlarged prostate) that caused urinary difficulty. A review of Resident 1's care plan dated 6/9/22 indicated, Foley Catheter Care. Cleanse with: warm water, mild soap, clean cloth, pat dry .every shift for UTI (urinary tract infection) prevention measures. A review of the facility's policy titled, Catheter Care, Urinary revised September 2014, indicated that the purpose of catheter care was to prevent catheter-associated urinary tract infections. Under Infection Control, the policy indicated, Routine hygiene (e.g. cleansing of the meatal [opening of the resident's penis] surface during daily bathing or showering) is appropriate. A review of Resident 1's record titled, Lab Results Report dated 3/16/22, indicated that the resident had a urinary tract infection including over 100,000 organisms per milliliter of Escherichia Coli (an organism that lives in the intestinal tract and can infect the urinary tract through feces and incontinence). Review of Resident 1's Order Summary Report dated 3/18/22, indicated that the antibiotic medication Ciprofloxacin 500 milligrams was ordered One tablet by mouth two times a day for UTI for 5 days. Similarly, Invanz Solution (an injectable antibiotic) was ordered inject one gram [into the muscle] in the evening for UTI for seven days. In an observation on 11/29/22 at 11:05 am, Resident 1 was examined in the presence of a facility nurse and observed to have approximately a 5 centimeter (about 2 inches) sheet of loose, crusting, peeling yellowish discharge with crumbly areas of debris above his penis. When Resident 1's foreskin (skin covering the tip of the penis) was pulled back, the opening to his penis was reddened and the catheter had created a deep impression into his skin where crusty debris had collected and was not removed. In a concurrent interview and observation of Resident 1's foley catheter on 11/29/22 at 11:10 am, Licensed Vocational Nurse (LVN) A, who was a traveling nurse working at the facility, stated, it is not clean to me. It is crusted with a lot of discharge. I would expect CNAs [Certified Nursing Assistants] to pull back the resident's foreskin and make sure it is clean. Also during an interview on 11/29/22 at 11:10 am, Resident 1 stated that he did not get cleaned down there very well and that CNAs are supposed to give him peri care (care of the peritoneum, between the legs) but only a couple of them do it, and, the rest of them don't bother. He stated further that the facility brings in people who don't know what they're doing, some from an agency and some of the facility's own staff. Resident 1 stated that, They are supposed to take care of it because my catheter leaks around the tube and it gets red down there. The next thing you know, I have an infection. Resident 1 stated that he had a UTI several months ago that he suspected was from not being cleaned properly. In an interview on 11/29/22 at 12:05 pm, CNA A stated, [Resident 1] always has a crusty discharge. It's always been that way. The expectation is that we should be washing with soap and rinse and dry. CNA A acknowledged that the risk of not keeping Resident 1 clean was a UTI. In an interview on 11/29/22 at 12:30 pm, Director of Nursing (DON) A stated that generally, each shift should be looking at his catheter and providing peri-care, and that his care plan would be revisited to determine if additional interventions were needed.

Nov 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to meet this requirement when two of four residents stated that their clothing had been lost by the facility and other residents' clothing was observed in a lost and found closet. This resulted in a less home-like environment and had the potential to compromise residents' dignity and financial and psychosocial well-being. FINDINGS: Resident 1 was admitted to the facility with dementia, muscle weakness and failure to thrive [was not at his expected functional level], and arthritis of the knee. The facility's record also indicated that he had cognitive communication deficit, or the inability to make his needs known. In an interview on 10/31/22 at 10:38 am, Family Member (FM 1) stated that her husband came home and I had to get him new clothes again. I had gone out and gotten him clothes there and they lost them. They wanted me to replace them and give them the bill. She stated that he had to be dressed in a hospital gown because his clothing was missing. Resident 2 was admitted to the facility with Alzheimer's disease, failure to thrive, urge incontinence [need to void immediately] and a history of falls. In a concurrent observation and interview on 10/31/22 at 1:05 pm, Family Member (FM 2) was observed to be taking a bag of laundry inside the facility. She stated that she took her mother's belongings home to launder because things have been lost: lots of sweat pants and shirts, blankets. I wrote her name in them because the facility lost so many. In an interview on 10/31/22 at 2:45 pm, Resident 3, who is president of the facility's Resident Council, stated that she's been at the facility for five years. Resident 3 further stated, Things do come up missing even if you have your name in them. I've had several pieces missing. The majority of us have had something missing at some time or another. In an interview on 11/3/22 at 11:30 am, Laundry Aide A (LA A) stated, The CNAs are responsible for making sure residents' clothes are labeled. I have a label machine, but sometimes they don't do it. If the name isn't on the article of clothing, we aren't sure who it belongs to so we hang it in a closet where CNAs can pick it up or bring the resident back to look for something. In a concurrent observation, an estimated 50 to 100 articles of clothing were observed hanging in a closet near the laundry area. In an interview on 11/3/22 at 11:40 am, Social Services Director (SS A) stated that she was aware of Resident 1's clothing loss, three shorts and three shirts. If a name isn't on an article of clothing, the staff doesn't know where it belongs. Review of the facility's record titled Progress Note dated 10/10/22, indicated that social services found no clothing in Resident 1's closet as he was preparing to discharge home. Review of the facility's policy titled, Personal Property indicated that The resident's personal belongings and clothing shall be inventoried and documented upon admission and as items are replenished, and, The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to meet this requirement when two of six residents (Residents 1 and 2) were not cleaned after episodes of incontinence. This had the potential to result in skin breakdown, infection, illness, and loss of dignity. FINDINGS: Resident 1 was admitted to the facility with dementia, muscle weakness and failure to thrive [was not at his expected functional level], and arthritis of the knee. The facility's record also indicated that he had cognitive communication deficit, or the inability to make his needs known. Resident 2 was admitted to the facility with Alzheimer's disease, failure to thrive, urge incontinence [need to void immediately] and a history of falls. In an interview on 10/21/22 at 10:38 am, Family Member 1 (FM 1) stated that she had repeatedly visited the facility to find her husband sitting wet until his CNA came. In an interview on 10/31/22 at 1:05 pm, Family Member 2 (FM 2) stated that her mother has frequently been left to sit in her own stool (feces) and urine, and that she brings her own pads because the urine seeps through the pads and wets the entire bed. FM 2 further stated that her mother has dementia and reaches into her diaper and gets feces under her fingernails that stains them yellow, and it remains uncleaned by the CNAs until she mentions it. She stated, Almost every time I come here she is either wet or has had a bowel movement and is sitting in it. Today she was wet. Last week she was wet two days when I got there. I come in after morning rounds are done by the CNAs so they should have her changed by then. But she's always wet or has poop in her diaper. FM2 provided the surveyor with photographs she had taken of her mother's dirty yellowed nails and crusty yellow-brown material stuck to the back of her mother's hand. On 11/3/22 at 10:00 am, Resident 2 was observed to have visible crusted brown material lining the cuticles of her nails on her right hand, and the nails on that hand were stained yellow. During the observation, the Administrator (AA) entered the room and was asked to look at Resident 2's hand. He acknowledged that they were dirty and stated, We'll get the CNA to wash her up, and stated in a displeased tone that We had just conducted an all-staff meeting to address resident care. A review of the facility's record titled, CNA [Certified Nursing Assistant] Duties and Responsibilities dated 2003 indicated, Assist residents' bowel and bladder function, and, Keep residents clean and dry. The record also indicated that it is a CNA's responsibility to Assist residents with nail care.

Oct 2019 9 deficiencies

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of R106's EMR admission Record, dated [DATE], revealed the resident was admitted to the facility on [DATE]. Review of R106's EMR admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) of 15 out 15, which indicated the resident was cognitively intact. Review of R106's paper medical record Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], completed by Do Not Attempt Resuscitation/DNR (Allow Natural Death) was selected. Further review revealed Comfort-Focused Treatment was selected with the focus on maximizing comfort and to not perform full code treatments. The POLST form indicated that the DNR was not discussed with the resident. The POLST was signed by the facility's medical director on [DATE]. Further review revealed FM2 signed the POLST as the legally recognized decisionmaker. However, R106 was her own decision maker. Registered Nurse (RN) 130 also signed the POLST as the person assisting with the form. During an interview on [DATE] at 8:10 PM, the DON revealed it was her expectation the admission nurse would determine if the resident has capacity to sign for themselves or who is the legal decisionmaker. Then the nurse would present, explain, and complete the POLST form in its entirety with the resident or decisionmaker. During an interview on [DATE] at 8:30 PM, the Admissions Coordinator 84 revealed at the time she had FM2 sign the admission paperwork she, the Admissions Coordinator, did not know that R106 was her own decision maker. The admission Coordinator 84 further stated FM2 sent an email on [DATE], the day after the admission, with R106's advance directive; however, she overlooked it and did not discover she had the resident's advance directive in her email until [DATE]. Review of R106's Advance Directive, dated [DATE]th, 2014, revealed FM1 and FM2 were identified as agents who were to make healthcare decisions for the resident. Continued review of the advance directive revealed the directive should remain in full force and effect during any period when R106 was incapacitated or unable to give informed consent to medical treatment. Review of the Advance Directive also revealed R106 retained the power and the authority to continue making her own medical and healthcare decisions so long as she could give informed consent to the medical treatment. During an interview on [DATE] at 4:23 PM, R106 stated if she was found unresponsive at the facility, she would want CPR. During an interview on [DATE] at 7:17 PM, FM1 and FM2 revealed R106 did have a Durable Power of Attorney (POA)/Advance Directive that identified FM1 and FM2 as the healthcare decision maker. FM1 stated the POA was not in effect at this time and he has never had to use it as R106 has always been able to make her own decisions including signing her own paperwork. FM1 further stated the evening R106 was admitted , the resident told FM2 to sign the admission paperwork. FM2 stated no one explained to her what the difference between Do Not Resuscitate (DNR) and full code. FM1 stated he would expect CPR to be initiated on his mother as this was her wishes as well. Interview and record review, on [DATE] at 5:42 PM with LVN92 revealed if she was to discover R106 unresponsive, she would check the resident's code status by looking at the POLST in the resident's hard copy chart and then check the EMR to confirm the code status. Continued observation and interview revealed the LVN92 checked both the resident's POLST and the EMR and stated R106 was a DNR and if she was to discover the resident unresponsive, she would not start CPR and she would notify the family that the resident was unresponsive. During an interview on [DATE] at 2:20 PM, RN130 stated if she was to discover R106 unresponsive, she would first check the resident's hard copy chart and if the POLST indicated CPR, she would initiate CPR. RN130 verified that R106's POLST indicated DNR code status and therefore CPR would not be initiated. During an interview on [DATE] at 3:00 PM, the Medical Director revealed if a resident was cognitively intact, then the resident was the one who was to make the decision related to their advance directive/code status; however, the resident may request for their family to have input about the decision. The Medical Director also stated it was his expectation R106's advance directive would have been acknowledged when it was received by the facility. The Medical Director stated if a resident who wanted to be a full code did not receive CPR, that would be a major problem. Based on medical record review, staff interviews, and interviews with family members, it was determined the facility failed to obtain accurate code status for two residents (Resident (R) 212 and R106) of 39 residents whose records were reviewed regarding Advance Directives and code status. This failure had the potential to place all residents at risk for not having their health care decisions honored. The Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy on [DATE] at 9:51 AM under the area of Resident Rights for a facility failure to obtain accurate Physician Orders for Life-Sustaining Treatment (POLST) information and to ensure Advance Directives reflected the resident's or representative's wishes. The facility submitted five plans of removal on [DATE]. The fifth and final removal plan was submitted and approved on [DATE] at 7:37 PM. The plan included R212's code status was changed to reflect the resident's family's wishes for code status, correct completion of the POLST form and the entering of the correct code status in the medical record. The plan included R106's code status was changed to reflect the resident's decision and honor her request for code status. The plan also included a completed audit of all the residents' medical records for the presence of a POLST and Advance Directives that reflected the resident's or representative's wishes. The Administrator completed in-services with staff, that included the Social Service Director, regarding the policy and procedures for Advanced Directives. The licensed nurses were in-serviced to verify that the POLST, code status, and Advance Directives honored the resident's or resident representative's wishes. On [DATE], as a result of the facility's removal plan, review of R212's POLST form and Electronic Medical Record (EMR) revealed R212 was changed to a full code as per the resident's representative wishes. On [DATE], as a result of the facility's removal plan, review of R106's EMR, Advance Directive, and POLST all revealed the resident was changed to a full code as per her wishes. Findings: 1. Resident (R) 212's EMR admission Record form revealed the resident was admitted on [DATE] with diagnoses that included Parkinson's Disease, Acute Respiratory Failure with Hypoxia, Diabetes, Dementia with Behavioral Disturbance, and Stage 3 Chronic Kidney Disease. Review of the paper medical record admission Summary Progress Notes dated [DATE] revealed all the consents, including code status, needed to be signed by the responsible party. Code status indicates whether a resident wants cardiopulmonary resuscitation or to allow a natural death in the event of cardiac or respiratory arrest. The EMR Physician Orders dated [DATE] indicated the resident's code status was a Do Not Resuscitate (DNR) and the admission Record indicated the resident was a DNR, yet there was no documentation of advance directives and no completion of the POLST. The POLST document is a standardized medical order that documents a conversation between a provider and a resident with a serious illness or frailty towards the end of life. A POLST form allows emergency medical services to provide the treatment a patient wants during a medical crisis. Review of the paper medical record revealed that the POLST was not signed by the resident's representative. During an interview on [DATE] at 2:15 PM, the Medical Records Director (MRD) 115 confirmed the POLST, Advance Directive form, and admission forms were not completed until on [DATE]. During an interview on [DATE] at 3:45 PM, the admission Coordinator 84 verified the Advance Directives and POLST were not completed upon admission. She verified there was conflicting information regarding the legal representative. admission Coordinator 84 did not verify who was the legal representative for R212. During an interview on [DATE] at 10:24 AM, the Social Service Director stated she had spoken with the daughter-in-law on the telephone on [DATE], but never confirmed the code status. During an interview on [DATE] at 1:45 PM, Licensed Vocational Nurse (LVN) 92 confirmed the POLST form was signed by the physician but not the resident's representative. During an interview on [DATE] at 2:30 PM, LVN90 revealed she was the nurse on duty at the time R212 was admitted . She stated she entered the DNR status because the ambulance driver told her the resident's code status was a DNR. LVN90 verified that she did not contact the resident's representative concerning R212's code status on admission to the facility. During an interview on [DATE] at 3:05 PM, Registered Nurse (RN) 176 revealed the resident's daughter, who is the resident's representative, signed the POLST on the evening of [DATE] making R212 a full code. He verified he dated the POLST form [DATE] when it was not signed until [DATE]. He verified he had never been trained on the completion of the POLST. An interview with LVN92 on [DATE] at 4:25 PM revealed if R212 would cease respirations and pulse, she would refer to the code status on the admission Record in the EMR and refer to the POLST in the paper chart. If the POLST was blank, she would use the status on the admission Record which was a DNR for R212. On [DATE], as a result of the facility's removal plan, review of R212's POLST form and EMR revealed R212 was changed to a full code as per the resident's representative wishes.

CONCERN (D)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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Based on record review, interview, and policy review, it was determined the facility failed to ensure one of three residents (Residents (R) 79) reviewed for a decline in Activities of Daily Living (ADL) had a significant change of status assessment in a sample of 23 residents. This failure had the potential to affect residents who have a decline in function. Findings include: A review of R79's Electronic Medical Record (EMR) admission Record revealed an admission date of 12/04/15 and a readmission date of 02/05/17 with medical diagnoses that included low back pain, muscle weakness, and dementia. A review of R79's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/19 revealed R79 was coded for requiring supervision and set up only for transfers and limited assistance of one person for toileting. Review of the quarterly MDS with an ARD of 09/14/19 revealed R79 declined to requiring extensive assistance of one person for transfers and total dependence on staff for toileting. During an interview on 10/16/19 at 1:35 PM, the MDS Coordinator stated R79 should have been coded as a Significant Change of Status Assessment due to the two areas of decline. The MDS Coordinator verified that the Resident Assessment Instrument Manual was followed for completing MDS assessments. Review of the October 2018 Resident Assessment Instrument [RAI] Manual, showed on page 2-22: A significant change is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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Based on observation, interview, medical record review, and manual review, it was determined the facility failed to ensure accurate Minimum Data Set (MDS) assessments of diagnoses for two of 23 sampled residents (Resident (R) 32 and R56). This deficient practice had the potential to affect the facility's ability to provide services for specific diagnoses. Findings include: 1. A review of R32's Electronic Medical Record (EMR) admission Record revealed a facility admission date of 02/28/19 with medical diagnoses that included cognitive communication deficit, Parkinson's disease, major depressive disorder, and dementia with behavioral disturbance. A review of R32's EMR Minimum Data Set (MDS) assessments revealed: 14-day admission MDS, with an Assessment Reference Date (ARD) of 03/07/19, that had R32 coded for dementia, Parkinson's, depression (other than bipolar), and anxiety. A significant change MDS, with an ARD of 05/02/19, that had R32 coded for dementia, Parkinson's, depression (other than bipolar), anxiety, and psychotic disorder (other than schizophrenia). A quarterly MDS, with an ARD of 08/02/19, that had R32 coded for dementia, Parkinson's, depression (other than bipolar), anxiety, and psychotic disorder (other than schizophrenia). During an interview on 10/16/19 at 1:28 PM, the MDS Coordinator stated she coded the 08/02/19 MDS assessment for psychotic disorder, because he is on Seroquel [antipsychotic medication] and has dementia with behavioral disturbance which I thought was synonymous with psychosis. During an interview on 10/16/19 at 2:37 PM, the Director of Nursing (DON) stated she did not know if dementia with behavior disturbance is the same as psychosis. Review of the Resident Assessment Instrument Manual for MDS coding revealed no directions regarding coding dementia with behavior disturbance as psychotic disorder. 2. During an observation and interview on 10/15/19 at 7:30 AM, R56 was in bed and noted to have an above the knee amputation of the left leg. R56 stated the amputation occurred two years ago. Review of R56's Electronic Medical Record (EMR) revealed an undated admission Record with an admission date of 12/01/17 with diagnoses of type 2 diabetes mellitus with other circulatory complications and acquired absence of left leg above the knee. Review of R56's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/05/18 specified in Section I: Active Diagnoses Acquired Absence of Left Leg Above Knee. Review of R56's EMR quarterly MDS assessment, with an ARD of 09/04/19, revealed Section I: Active Diagnoses no documentation of the acquired absence of left leg above the knee. During an interview on 10/16/19 at 6:10 PM, the MDS Coordinator 14 was asked about the missing diagnosis. The MDS Coordinator 14 stated, It was missed. During an interview on 10/16/19 at 6:40 PM, the Director of Nursing (DON) agreed the assessment was not accurate and the expectation was to have an accurate assessment. The DON was asked for policy and procedure. The DON stated the facility follows the Resident Assessment Instrument (RAI) manual. Review of the RAI manual dated October 2019, page I-1 , Section I: Active Diagnoses, Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status .

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

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 review of the facility's policy, it was determined the facility failed to ensure accurate Level I Preadmission Screening and Resident Review (PASARR) prior to admission to the facility for three of 23 sampled residents (Resident (R) 108, R40, and R65). This failure had the potential for residents to not receive specialized services for mental disorders and intellectual disabilities. Findings: A review of the facility's policy titled, admission Criteria, revised March 2019, revealed all new admissions and readmissions were screened for mental disorders (MD), intellectual disabilities (ID), or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. Continued review of the policy revealed the facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for a MD, ID, or RD. Further review of the policy revealed if the Level I screen indicated that the individual may meet the criteria for a MD, ID, or RD, he or she was referred to the state PASARR representative for the Level II (evaluation and determination) screening process. 1. Review of R108's Electronic Medical Record (EMR) admission Record, dated 10/15/19, revealed the facility admitted the resident on 09/25/19 with diagnoses which included Major Depressive Disorder and Anorexia. Review of R108's EMR Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 09/30/19, revealed the facility assessed the resident to have diagnoses which included depression, other than bipolar. Review of R108's paper medical record Preadmission Screening and Resident Review (PASARR) Level I Screening Document, dated 09/25/19, revealed it was completed by the Admissions Director. Further review of R108's Level I PASARR revealed for question number 26, Does the resident has a diagnosed mental disorder such as Schizophrenia/Schizoaffective Disorder, Psychotic/Psychosis, Delusional, Depression, Mood Disorder, Bipolar, or Panic/Anxiety, the choices for answers of Yes and No were blank. 2. Review of R40's EMR admission Record, dated 10/15/19, revealed the resident was admitted to the facility on [DATE] with diagnoses which included major depressive disorder. Review of R40's EMR MDS assessment with an ARD of 06/26/19, revealed the facility assessed the resident to have diagnoses which included depression, other than bipolar. Review of R40's paper medical record Preadmission Screening and Resident Review (PASARR) Level I Screening Document, dated 06/19/19, revealed it was completed by the Admissions Director. Further review of R40's Level I PASARR revealed for question number 26, Does the resident has a diagnosed mental disorder such as Schizophrenia/Schizoaffective Disorder, Psychotic/Psychosis, Delusional, Depression, Mood Disorder, Bipolar, or Panic/Anxiety, No was selected. 3. Review of R65's EMR admission Record, dated 10/15/19, revealed the resident was admitted to the facility on [DATE], with diagnoses which included schizophrenia and anxiety disorder. Review of R65's EMR annual MDS assessment with an ARD of 09/10/19, revealed the facility assessed the resident to have diagnoses which included anxiety disorder and schizophrenia. Review of R65's paper medical record Preadmission Screening and Resident Review (PASARR) Level I Screening Document, dated 09/05/17, revealed it was completed by the Admissions Director. Further review of R65's Level I PASARR revealed for question number 26, Does the resident have a diagnosed mental disorder such as Schizophrenia/Schizoaffective Disorder, Psychotic/Psychosis, Delusional, Depression, Mood Disorder, Bipolar, or Panic/Anxiety, No was selected. An interview, on 10/16/19 at 8:10 PM, with the Director of Nursing (DON) revealed it was her expectation that residents' PASARR's would be completed correctly. The DON stated accuracy was important to ensure any specialized services needed would be provided for the residents. An interview, on 10/16/19 at 8:30 PM, with the Admissions Coordinator revealed she could not identify a reason why question 26 of the PASARR for R108 was left blank. The Admissions Coordinator stated she did not complete the PASARR's for R40 and R65 but that they were completed by persons no longer employed by the facility. Interview, on 10/16/19 at 9:25 PM, with the Administrator revealed it was his expectation the admission Coordinator would have completed the PASARR's correctly. The Administrator verified that accuracy was important to identify possible additional resources for the residents.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, interview, record review, and manual review, it was determined the facility failed to ensure a care plan was developed for one of 23 sampled residents (Resident (R) 70) who was assessed as being edentulous (missing teeth). This failure had the potential to affect care planning for other residents with dental concerns. Findings: An observation on 10/14/19 at 11:17 AM and 12:01 PM, revealed R70 appeared to have no teeth or dentures. Review of the Electronic Medical Record (EMR) admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/12/19, revealed R70 was coded as being edentulous, having no natural teeth or tooth fragments. A review of the EMR Care Area Assessments (CAA) associated with the 06/12/19 MDS revealed that Dental was triggered and was to be care planned. A review of R70's care plans revealed no plan of care had been developed regarding her having no teeth. During an interview on 10/16/19 at 1:10 PM, the Director of Nursing (DON) stated if dental triggered on the CAA, she would expect it would go to a care plan and then forwarded to Social Services so the resident could be put on the dental visit list. During an interview on 10/16/19 at 1:23 PM, the MDS Coordinator verified that no dental care plan had been developed but it should have been. A review of the October 2018 Resident Assessment Instrument (RAI) Manual, page 4-2 showed: The CAA process framework. The CAA process provides a framework for guiding the review of triggered areas, and clarification of a resident's functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. The assessment of the causes and contributing factors gives the interdisciplinary team (IDT) additional information to help them develop a comprehensive plan of care .

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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Based on medical record review, interview, and policy review, it was determined the facility failed to ensure one of three residents (Resident (R) 79) reviewed for a decline in activities of daily living in a sample of 23 was provided screening and/or services to regain lost function. This failure had the potential to affect other residents who have had a decline in function. Findings include: Review of R79's Electronic Medical Record (EMR) admission Record revealed an admission date of 12/04/15 and a readmission date of 02/05/17, with medical diagnoses that included low back pain, muscle weakness, and dementia. Review of R79's EMR quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/13/19 revealed R79 was coded for requiring supervision and set up only for transfers and limited assistance of one person for toileting. Review of the quarterly MDS with an ARD of 09/14/19 revealed R79 declined to requiring extensive assistance of one person for transfers and total dependence on staff for toileting. In an interview on 10/15/19 at 10:03 AM, the MDS Coordinator stated, based on the declines coded in Transfers and Toilet Use, [R79 name] should have been referred for therapy. In an interview on 10/16/19 at 1:10 PM, the Director of Nurses (DON) stated she felt the resident should have been referred to therapy for the decline in transfer and toilet use. A review of the facility policy Activities of Daily Living (ADLs), Supporting, dated March 2018, revealed: Policy Statement: Residents will [sic] provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) . Policy Interpretation and Implementation 1. Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable .

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, it was determined the facility failed to ensure a dependent resident received thorough incontinence care in the one of 23 sampled residents (Resident (R) 73). This failure had the potential to affect residents who depended on staff for hygiene. Findings: A review of the Electronic Medical Record (EMR) admission Record revealed R73 was admitted to the facility on [DATE]. A review of the EMR quarterly Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of three out of 15, which indicated severe cognitive impairment. The assessment revealed the resident was totally dependent of one to two staff for activities of daily living, including toileting, personal hygiene, and bathing. The resident was always incontinent of urine and bowel. On 10/13/19 at 11:20 AM there was a very strong urine and stool odor detected in the hall. Registered Nurse (RN)133 verified the odor in the hall. RN133 requested the Certified Nursing Assistant (CNA)67 check the two residents in room [ROOM NUMBER]. R73 was observed in bed. There was a very strong odor of stool and urine in the room. CNA67 changed the brief which had a large amount of urine. The resident had a small amount of dark stool near the rectum. CNA67 wiped some of the stool but started to put a brief on R73 without thoroughly removing the stool. CNA67 did not clean the groin/perineal area. He replaced the brief. The CNA repositioned the resident, disposed of the garbage, and washed his hands. During an interview on 10/13/19 at 11:50 AM, CNA67 verified he did not thoroughly wipe away the stool or do any type of perineal care for R73. Review of the EMR Care Plans revealed a care plan dated 10/16/2019 for bowel and bladder incontinence. The interventions included to change promptly and clean perineal area after each incontinent episode. Review of the Perineal Care policy, revised February 2018, indicated .The staff was to glove and wash the perineal area with soap and water with a washcloth. Dry the perineum gently. Wash and rinse the rectal area and dry thoroughly .

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 policy review, the facility failed to ensure effective hand hygiene was performed during the wound care for one of three residents (Residents (R) 107) observed for wound care in a sample of 23 residents. This failure had the potential for spread of infection to other vulnerable residents. Findings: A review of R107's Census tab in the Electronic Medical Record (EMR) showed a facility admission date of 07/29/19. Review of the Medical Diagnosis tab in the EMR showed R107 was admitted with diagnoses that included stage 4 sacral area pressure ulcer and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). Observation of R107's pressure ulcer sacral wound care on 10/15/19 showed Licensed Vocational Nurse (LVN) 91 entered the resident's bathroom at 10:13 AM and completed a hand wash procedure that included an 11 second hand scrub time. During the remainder of the procedure: -at 10:17 AM, performed a hand wash with a 7 second hand scrub from dispensing of soap to activation/tear off of paper towel -at 10:19 AM, performed a hand wash with a 10 second hand scrub from soap dispense to activation/tear off of paper towel -at 10:22 AM, performed a hand wash with a 9 second hand scrub from soap dispense to activation/tear off of paper towel -at 10:24 AM, performed a hand wash with a 7 second hand scrub from soap dispense to activation/tear off of paper towel -at 10:26 AM, performed a hand wash with a 10 second hand scrub from soap dispense to activation/tear off of paper towel -at 10:29 AM, performed a hand wash with a 13 second hand scrub from soap dispense to activation/tear off of paper towel. During an interview on 10/15/19 at 10:55 AM, LVN91 stated effective hand hygiene should have about a 30 second scrub time. During an interview on 10/16/19 at 4:57 PM, the Director of Nursing (DON) stated an expectation that the hand scrub portion of a hand wash procedure would take the time to sing Happy Birthday twice - about 30 seconds. A review of the facility policy Handwashing/Hand Hygiene, showed: .Procedure . Washing Hands l. Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) under a moderate stream of running water, at a comfortable temperature. Hot water is unnecessarily rough on hands. 2. Rinse hands thoroughly under running water. Hold hands lower than wrists. Do not touch fingertips to inside of sink. 3. Dry hands thoroughly with paper towels and then turn off faucets with a clean, dry paper towel. 4. Discard towels into trash .

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation, on 10/13/19 at 1:44 PM, of room [ROOM NUMBER] revealed the bathroom sink cold-water metal faucet knob was jagged with a sharp edge in need of repair. Continued observation revealed R19 and R49 resided in the room. During a concurrent observation and interview, on 10/14/19 at 2:46 PM, Licensed Vocational Nurse (LVN) 108, who was the nurse assigned to R19 and R49, revealed when looking at the cold-water faucet knob, she was concerned that it was broken and jagged. Continued interview revealed both R19 and R49 independently used the restroom and independently washed their hands. The LVN stated the residents could possibly received a skin tear from turning on the cold water. During an interview, on 10/14/19 at 2:58 PM, Certified Nursing Assistant (CNA) 13 verified R19 and R49 go to the bathroom independently and could possibly get a skin tear from turning on the water. During an interview, on 10/15/19 at 3:01 PM, the Maintenance Supervisor, revealed both the nursing staff and maintenance staff should have identified the faucet knob and reported it to be replaced. Continued interview revealed the maintenance staff did not do rounds in the rooms where they could have identified the issue with the sink. The Maintenance Supervisor stated the residents could have sustained a cut from the faucet knob. During an interview, on 10/16/19 at 8:10 PM, the Director of Nursing (DON) revealed it was her expectation that the faucet knob would have been identified and fixed immediately. The DON stated it was important to have the faucet knob repaired for the safety of the residents due to possible skin tears. During an interview, on 10/16/19 at 9:25 PM, the Administrator revealed it was his expectation the water faucet knob should be identified by staff and fixed immediately due to the possibility of a resident receiving a skin tear. Review of the facility policy titled, Hazardous Areas, Devices and Equipment with a revised date of July 2017 revealed, Policy Statement All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible . Identification of Hazards l. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: a. Equipment and devices that are left unattended or are malfunctioning; b. Devices and equipment that are improperly used or poorly maintained . Assessment and Analysis of Hazards . 2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous . 4. Resident vulnerability to hazards may change over time. Ongoing assessment helps identify when elements in the environment pose hazards to a particular resident . Based on observation, interview, and facility policy review, the facility failed to ensure a safe environment for three of 23 sampled residents (Resident (R) 12, R19, and R49). This deficient practice had the potential to affect the facility's ability to provide a safe environment for the residents living in the building. Findings: 1. During an observation on 10/14/19 at 8:58 AM, in R12's room there were decorations of an [NAME] laying across the light fixture above the resident bed and a cloth pumpkin in the middle set on top of the light. During an observation on 10/15/19 at 7:55 AM, in R12's room there were decorations of an [NAME] laying across the light fixture above the resident bed and a cloth pumpkin in the middle set on top of the light. During an observation on 10/15/19 at 3:18 AM, in R12's room there were decorations of an [NAME] laying across the light fixture above the resident bed and a cloth pumpkin in the middle set on top of the light. During an interview on 10/15/19 at 4:02 PM, the Maintenance Director was asked to look at R12's room and asked if he noted any issue with the room. The Maintenance Director stated that the decorations on the light should not be there because that is a fire hazard. The Maintenance Director was asked if room checks were done to ensure that fire hazards like those found in R12's room were recognized. He stated, Not at this time.

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

• 41% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 3 harm violation(s), $88,927 in fines. Review inspection reports carefully.
• 73 deficiencies on record, including 3 serious (caused harm) violations. Ask about corrective actions taken.
• $88,927 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
• Grade F (25/100). Below average facility with significant concerns.

Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Bridgeview Post Acute's CMS Rating?

CMS assigns BRIDGEVIEW POST ACUTE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Bridgeview Post Acute Staffed?

CMS rates BRIDGEVIEW POST ACUTE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 41%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Bridgeview Post Acute?

State health inspectors documented 73 deficiencies at BRIDGEVIEW POST ACUTE during 2019 to 2025. These included: 3 that caused actual resident harm and 70 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Bridgeview Post Acute?

BRIDGEVIEW 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 WEST HARBOR HEALTHCARE, a chain that manages multiple nursing homes. With 130 certified beds and approximately 114 residents (about 88% occupancy), it is a mid-sized facility located in YUBA CITY, California.

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

Compared to the 100 nursing homes in California, BRIDGEVIEW POST ACUTE's overall rating (2 stars) is below the state average of 3.1, staff turnover (41%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Bridgeview 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 Bridgeview Post Acute Safe?

Based on CMS inspection data, BRIDGEVIEW 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 2-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Bridgeview Post Acute Stick Around?

BRIDGEVIEW POST ACUTE has a staff turnover rate of 41%, 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 Bridgeview Post Acute Ever Fined?

BRIDGEVIEW POST ACUTE has been fined $88,927 across 2 penalty actions. This is above the California average of $33,968. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Bridgeview Post Acute on Any Federal Watch List?

BRIDGEVIEW 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: 130
Avg. Residents: 114
Occupancy: 87.7%
Ownership: For profit - Limited Liability company
Chain: WEST HARBOR HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
3 Actual Harm citations: -15
73 Deficiencies: -10
Fines ($88,927): -10
Final Score: 25/100

Nearby Alternatives

FOUNTAINS, THE 5-star YUBA CITY POST ACUTE 4-star RIVER VALLEY CARE CENTER 3-star

View all in YUBA CITY →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056346