Does YUCAIPA HILLS POST ACUTE have any serious inspection findings?

Yes, YUCAIPA HILLS POST ACUTE has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 41 total deficiencies from recent inspections.

What are the staffing levels at YUCAIPA HILLS POST ACUTE?

YUCAIPA HILLS POST ACUTE has a two-star staffing rating from CMS with 0.27 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 YUCAIPA HILLS POST ACUTE located?

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

How many beds does YUCAIPA HILLS POST ACUTE have?

YUCAIPA HILLS POST ACUTE has 82 certified beds.

Who owns YUCAIPA HILLS POST ACUTE?

YUCAIPA HILLS POST ACUTE is a for profit - limited liability company facility and operates independently (not part of a chain).

What questions should families ask when visiting YUCAIPA HILLS POST ACUTE?

Families visiting YUCAIPA HILLS POST ACUTE should ask about staff retention and training programs, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does YUCAIPA HILLS POST ACUTE compare to other nursing homes?

YUCAIPA HILLS 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.

YUCAIPA HILLS POST ACUTE

Name: YUCAIPA HILLS POST ACUTE
Address: 13542 SECOND ST., YUCAIPA, CA, 92399, US
Telephone: (909) 795-2421
Rating: 2.0

13542 SECOND ST., YUCAIPA, CA 92399 · (909) 795-2421

For profit - Limited Liability company 82 Beds Independent Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#962 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

Yucaipa Hills Post Acute has received a Trust Grade of F, indicating significant concerns about the quality of care provided. They rank #962 out of 1155 facilities in California, placing them in the bottom half, and #51 out of 54 in San Bernardino County, meaning there are very few better options nearby. Although the facility has shown improvement, reducing critical issues from 12 in 2024 to just 1 in 2025, the overall situation remains troubling. Staffing is a weakness, with a 60% turnover rate that is notably higher than the state average, and RN coverage is lower than 83% of facilities, which may affect the quality of care. Specific incidents of concern include unsanitary food preparation practices leading to pest infestations, and a critical incident where a resident eloped from the facility, highlighting safety and oversight issues.

Trust Score: F
In California: #962/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $31,899 in fines. Lower than most California facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 41 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 12 issues

2025: 1 issues

The Good

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

Facility shows strength in fire safety.

The Bad

2-Star Overall Rating

Below California average (3.1)

Below average - review inspection findings carefully

Staff Turnover: 60%

14pts above California avg (46%)

Frequent staff changes - ask about care continuity

Federal Fines: $31,899

Below median ($33,413)

Moderate penalties - review what triggered them

Staff turnover is elevated (60%)

12 points above California average of 48%

The Ugly 41 deficiencies on record

3 life-threatening 1 actual harm

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

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 the prevention of avoidable accidents for one of three sampled residents (Resident 1) when Resident 1, a resident who was at high risk for falls and fully dependent upon staff for mobility while in bed, fell from his bed while being changed by Certified Nursing Assistant 1 (CNA 1). This failure resulted in Resident 1 to sustain a head injury which included a bleeding laceration to his right eyebrow and a subarachnoid hemorrhage (bleeding in the area between your brain and the thin tissues that cover and protect it). Findings: During a review of Resident 1's admission Record (contains medical and demographic information), the record indicated Resident 1 was admitted on [DATE], with diagnoses which included cerebral palsy (neurological disorder that causes permanent problems with movement, balance, and posture), parkinson's disease (a disorder of the central nervous system that affects movement), disorders of bone density and structure (medical conditions that affect the strength and composition of bones which can significantly impact bone structure and increase fracture risk), and epilepsy (a brain disorder that causes recurring, unprovoked seizures). During an interview on November 4, 2024, at 3:25 PM, with the Director of Nursing (DON), the DON stated on October 18, 2024, Resident 1 fell off his bed when CNA 1, who was a contracted registry staff member (an employee provided by a contracted staffing agency), turned the resident away from her (rolled the resident towards the opposite side of the bed from which the CNA was standing) when cleaning up the resident's bowel movement. During a continued interview on November 4, 2024, at 3:35 PM, with the DON, the DON stated CNA 1 should have had another staff member assist with turning the resident in bed since the resident had contractures (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). The DON further stated as a result of the fall, Resident 1 sustained an abrasion to his right eyebrow and was subsequently sent to the hospital where it was identified that the resident also had a subarachnoid hematoma. During a review of Resident 1's Minimum Data Set assessment (MDS - a computerized resident assessment tool), dated October 18, 2024, the MDS assessment indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a tool used to screen and identify the cognitive condition of residents upon admission into a long-term care facility) score of 1 (score of 0-7 is severe cognitive impairment). During a further review of Resident 1's MDS assessment, dated October 18, 2024, section GG (section regarding functional abilities), indicated for rolling left and right in bed, Resident 1 was dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 [two] or more helpers is required for the resident to complete the activity. During a review of Resident 1's fall assessment titled, Fall Risk Assessment, (a scored assessment of Resident 1's fall risk) dated October 20, 2024, the fall risk assessment indicated Resident 1 was identified to be at high-risk for falls, with a score of 14. The document further indicated, .If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls . During a review of Resident 1's care plan (an individualized plan for the medical care of a resident) (untitled), dated April 14, 2023, the care plan indicated, [Name of Resident 1] is high risk for falls r/t [related to] confusion .balance problems, incontinence [involuntary loss of bowel or bladder control], poor communication/comprehension, psychoactive drug use [A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior], unaware of safety needs .goal the resident will be free of falls through the review date . interventions included, Anticipate and meet the resident's needs .follow facility fall protocol. During a review of the written statement from CNA 1, dated October 18, 2024, the statement indicated, at approx. [approximately] 5:30-5:40 [AM] I was providing patient care to [Name of Resident 1] who had BM and urine spillage since his previous brief was shifted while wiping and cleaning mattress I had patient turned facing the door when patient fell off the bed that was about mid-thigh height. I imeddiately [sic] notified nurse and put patient back on mattress. Patient hit his face on floor resulting in cut to the side of his eye. CNA 1 was not available for interview. During a review of Resident 1's hospital paperwork from [name of Hospital] the document titled, History of Present Illness, dated October 18, 2024 indicated, BIBA [brought in by ambulance] from care facility for evaluation s/p [status post] fall that occurred this morning .CT head shows small subarachnoid hemorrhage along the bilateral bifrontal sulci [portion of the frontal lobe of the brain] .Condition: serious . During a review of the facility's policy and procedure (P&P) titled, Fall Prevention, dated December 2023, the P&P indicated, It is the policy of this facility to investigate the circumstances surrounding each resident fall and implement actions to reduce the incidence of additional falls and minimize potential for injury .

Oct 2024 9 deficiencies 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** An immediate jeopardy (IJ- a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on October 16, 2024, at 4:53 PM, regarding the elopement of Resident 27 from the facility on October 16, 2024. An IJ was called in the presence of the Administrator. A corrective action plan was requested on October 16, 2024, at 4:53 PM. The immediate Jeopardy was removed after the corrective action plan was verified to be implemented through observations interviews, and record reviews on October 17, 2024, at 2:46 PM in the presence of the Administrator. Free of Accident Hazards / Supervision/Devices CFR (s): 483.25(d)(2)(2) §483.25 (d) Accidents. The facility must ensure that. §483.25(d)(1) The resident environment remains as free of accidents hazards as is possible; and §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide supervision to one of 36 residents (Resident 27) in the locked memory care unit (a locked unit which is a secure area within the skilled nursing facility where people with dementia live. The locked unit prevents the residents from wandering off or leaving the facility willingly) on October 16, 2024, when staff was unaware Resident 27 (a confused resident with cognitive deficit and a history of falls) had left the facility. It was not until Surveyor 1 (a member of a survey team not employed by the facility) informed facility staff that the resident had eloped (the act of leaving the premises or safe area without authorization or supervision to do so) and was in a field adjacent to the facility building. This failure had the potential to result in serious harm or death to Resident 27 who was at risk for injuries which may occur as a result of being exposed to environmental elements, accident hazards or being without resources such as food, water and shelter. Findings: During a review of Resident 27's clinical record, the admission Record (contains medical and demographic information), it indicated Resident 27 was initially admitted to the facility on [DATE], with diagnoses which included dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering, and reasoning, that interferes with daily life), encephalopathy (any brain disease, disorder, or damage that affects the brain's structure or function), altered mental status, fall on or from other stairs and steps [subsequent encounter], unsteadiness on feet, and hemiplegia (paralysis on one side of the body). During a review of Resident 27's Minimum data set (MDS - an assessment of a residents functional and health status), dated August 19, 2024, section GG0115 indicated Resident 27 had lower extremity impairment on both sides (impairment in both legs) in section, Functional Limitation in Range of Motion -code for limitation that interfered with daily functions or placed resident at risk of injury in the last 7 days . Further review of Resident 27's MDS dated [DATE], indicated the type of assistance the resident required for walking 10 feet included, supervision or touching assistance - helper provides verbal cues and/or touching/steadying and/or contact guard assistance [caregiver places one or two hands on the patient's body to help with balance but provides no other assistance to perform the functional mobility task] as resident completes activity . During a review of Resident 27's Interdisciplinary Team Note (IDT - A group of professionals from different disciplines that work together to meet the needs of residents using their different perspectives and expertise.), dated October 16, 2024, the IDT note indicated Resident 27 had .confusion and disorientation secondary to diagnosis of dementia. His BIMS score [Brief Interview for Mental Status score - a score of 0-15 used to determine cognitive functioning] is 6 [severe impairment] and does not have the capacity to make decisions . During a review of Resident 27's Physical Therapy PT Evaluation & Plan of Treatment, with a certification period of July 30, 2024, through August 28, 2024, the physical therapy evaluation indicated, .Reason for referral/current illness: Patient referred to PT [physical therapy] due to new onset of decrease in functional mobility, falls/fall risk and increased need for assistance from others .PMHX [past medical history] Pt [patient] .change in function post fall with facial bruising .hx [history] of fall at home with difficulty walking and encephalopathy . and decreased cognition . Further review of the Physical Therapy PT Evaluation & Plan of Treatment, indicated the resident had impaired functioning in his left and right hip, knee, and ankle and his Safety Awareness was impaired. During a review of Resident 27's care plan (an individualized plan for the medical care of a resident), titled, [name of Resident 27] has hesitancy to ambulate [walk] and unsteady shuffling gait which limits physical mobility, dated September 9, 2024, the care plan indicated, .Goal .will remain free of complications related to immobility, including .fall related injury through the next review date .will maintain current level of mobility 2 person assist for 15 ft [feet] through review date .Interventions - Provide supportive care, assistance with mobility as needed . During an observation on October 16, 2024, at 11:08 AM, Resident 27 was observed by Surveyor 1 to be walking unassisted in a field behind the facility's parking lot. There was no staff nearby or within eyesight of the resident. During an interview on October 16, 2024, at 11:11 AM, the Administrator (ADMIN) was informed by Surveyor 1 that Resident 27 was in a field next to the parking lot and was unaccompanied by staff. During an interview on October 16, 2024, at 12:15 PM, with the ADMIN, the ADMIN stated supervision in the locked memory care unit included a supervising Licensed Vocational Nurse (LVN), and Certified Nursing Assistants (CNAs) with a one to 10 ratio (1 CNA per 10 residents). The ADMIN further stated on October 16, 2024, it was a surveyor (Surveyor 1) who initially informed him that Resident 27 had left the facility and was in a field. The ADMIN stated facility staff were unaware Resident 27 had left the facility prior to notification from the surveyor. The ADMIN stated he believed Resident 27 had exited out the facility door (which led to the outside) at the far end of a hallway, within the locked memory care unit, and then jumped over a locked gate. Upon being brought back into the facility by staff, the ADMIN stated Resident 27 told him he had jumped over the locked gate. The ADMIN further stated the facility exterior door remained unlocked, but the gate was locked with a keypad code that staff would enter and exit the facility through to gain access to the laundry room and garbage dumpster. When asked if the facility exterior door had an audible alarm to indicate the door had been opened, the ADMIN stated the door had not been alarmed since he started working at the facility within the last three years. During an interview on October 16, 2024, at 12:26 PM, with Certified Nursing Assistant 1 (CNA 1) stated on October 16, 2024, he was at lunch when he received a phone call at 11:13 AM from CNA 2 informing him Resident 27 had left the facility building and was in a field. CNA 1 further stated there was supposed to be at least one CNA stationed in each of the two halls in the memory care unit to provide supervision to the residents. CNA 1 stated he informed CNA 2 and a charge nurse that he was going to lunch, and it was CNA 2 who was supposed to be supervising residents while he was at lunch at the time Resident 27 eloped. CNA 1 stated the door leading to the exterior of the building (in the hall in which Resident 27 allegedly eloped from), used to have an alarm in the past but did not any longer. During an interview on October 16, 2024, at 12:43 PM, with CNA 2, CNA 2 stated the memory care unit (two total hallways) was supposed to have at least one CNA supervising each hallway. CNA 2 further stated there was usually four CNAs assigned to the memory care unit (2 for each hallway), but at the time Resident 27 had eloped, the two CNAs (CNA 1 and CNA 4) assigned to the hallway where Resident 27's room was located and where the door Resident 27 used to go outside was also located, were at lunch at the same time. CNA 2 stated she was assigned to the other hallway but was tasked with supervising both hallways. When asked where CNA 3 was (the third of four CNAs assigned to the memory care unit), CNA 1 stated CNA 3 was in the activity room (located in the memory care unit) and that CNA 3 was supposed to be helping her supervise the residents but did not know why CNA 3 was in the activity room instead. CNA 2 stated she also saw Licensed Vocational Nurse 1 (LVN 1) at the nurses' station in the memory care unit. During an interview on October 16, 2024, at 1:07 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated there were four CNAs assigned to the memory care unit to supervise residents. LVN 1 further stated the CNA's in the halls were supposed to take lunch opposite each other so there was one CNA at a time taking a lunch from each hallway. This would leave one CNA in each hallway to supervise residents. LVN 1 stated she was just covering the lower dementia [locked memory care unit] unit as extra eyes while LVN 2 was at lunch. LVN 1 further stated she was aware CNA 1 was on lunch but didn't know if any of the other CNAs were on lunch or break. LVN 1 stated she saw CNA 2 supervising the hallways but didn't see any other CNAs in the hallways. LVN 1 stated she was aware CNA 3 was providing supervision to residents in the activity room. LVN 1 stated LVN 2 came back from her lunch at approximately 11:05 AM and she (LVN 1) then went to lunch while LVN 2 went to go check a resident's blood sugar (test to determine the level of sugar in the blood) in a resident's room. During an interview on October 16, 2024, at 1:30 PM, with LVN 2, LVN 2 stated she came back from lunch and at the time Resident 27 eloped, she was doing a blood sugar check on a resident in the resident's room. LVN 2 further stated she knew CNA 1 was supervising the halls but did not know where CNA 4 was. During an interview on October 16, 2024, at 1:39 PM, with CNA 3, CNA 3 stated she was supervising the hallways earlier in the day but was asked by an activities staff member to come and help provide supervision in the activities room because there was more than 10 residents in the activity room and they needed more than 1 staff member to provide supervision. CNA 3 further stated she was aware CNA 1 and CNA 4 were on lunch which meant there was only her and CNA 2 left to supervise the hallways but stated she (CNA 3) could only be in one place at a time so she decided to go to the activity room to help the activities staff member. CNA 3 stated after approximately 20-30 minutes of being in the activity room, she was walking back to the hallway from the activity room when she was made aware Resident 27 had eloped. During a concurrent observation and interview on October 16, 2024, at 5:24 PM, with Resident 27, Resident 27 was observed to be in his room which was located immediately adjacent to a facility exit door located at the end of the hallway where there was a locked gate upon exiting the building. Resident 27 was alert and oriented x (times) 1 (one) (oriented to person but not oriented to place, time, or situation). Resident 27 stated he didn't know where he was, what day or month it was and stated he thought he was on TV during our discussion. Resident 27 was unable to answer if he recalled if or how he left the facility. During an interview on October 18, 2024, at 9:59 AM, with the Director of Staff Development (DSD), the DSD stated the staffing schedule (in use at the time Resident 27 eloped) did not indicate who was supposed to cover each hallway during staff breaks and lunches and it was facility practice to ensure verbally with each other that there was someone in each hallway to supervise residents. During a review of the facility's policy and procedure (P&P) titled, Elopement/Unsafe Wandering, dated December 2023, the P&P indicated, This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement .Elopement is when a resident leaves the facility premises or a safe area without authorization (i.e. [for example] an order for discharge or leave of absence) and/or any necessary supervision to do so . An Immediate Jeopardy (IJ-a situation that has threatened or is likely to threaten the health and safety of a resident) was called under F689 §483.25(d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents on October 16, 2024 at 4:53 PM, after it was determined that Resident 27 did not receive supervision and monitoring required to keep the resident safe on October 16, 2024, when the resident was found to have eloped from the facility and was found by a surveyor in a field behind the facility's parking lot. The IJ was called in the presence of the Administrator (ADMIN). A Corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested and a preliminary CAP was received on October 17, 2024, at 12:48 PM and included the following: - On October 16, 2024, upon notification of incident, Resident 27 was assessed by the Director of Nursing (DON) and a physician. Body assessment was done with no apparent injury. The attending physician ordered Complete Blood Count (CBC - blood tests), Complete Metabolic Panel (CMP-blood tests) and Urinalysis with culture and sensitivity (urine tests) STAT (immediately). - Resident 27 was placed on 72-hour change of condition (change in a resident's health or functioning that can be short-term or significant) monitoring and 1:1 (one on one) supervision with closed visual check. No change was noted related to incident. - On October 16, 2024, the Facility Administrator installed a functional audio alarm system on all exit doors in the lower unit. - All exterior doors in the lower/Memory care unit will be checked every 15 minutes by a designated staff for the next 30 days along with the installation of alarm system. - Director of Nursing and designees evaluated 80 residents' elopement and wandering risk on October 16, 2024, to identify any residents that were at high risk for elopement and wandering. No other residents were affected. - Director of Nursing and designees ensured that identification of all 80 residents was in place such as wrist bands and or photo on the electronic medical record (PCC) on October 16, 2024. All residents had a wrist band and/or photos were uploaded in PCC. - Facility staff received an in-service and training from the Director of Staff Development (DSD) on October 16, 2024, regarding Policy and Procedure Incident/Accident with emphasis with Elopement/Wandering Incidents. In-services will continue October 17, 2024, and will be given to all staff before the beginning of their next shift. - Director of Staff Development initiated in-service with the Licensed Nurses and Certified Nursing Assistants on October 16, 2024, about coverage during breaks and lunch. The licensed nurse is responsible for creating the daily shift assignment form including the scheduled break and lunch time to ensure that the floor has adequate staff and supervision provided to the residents. In an event that a staff is running late for the scheduled break and lunch, it is the staff's responsibility to notify the Charge Nurse or Registered Nurse (RN) supervisor so that, if necessary, the Licensed Nurse can make the adjustment to ensure adequate supervision is provided to the residents. In-services will continue October 17, 2024 and be given to all licensed nurses and certified nursing assistants before the beginning of their next shift. - Director of Staff Development and or Charge Nurse will ensure that daily shift assignment is completed and scheduled breaks and lunch time is covered. - Administrator initiated the in-service on October 16, 2024, regarding the policy, monitoring, and maintenance alarm system in all exterior door in the lower unit. - All Exterior doors in the lower unit will be checked every 15 minutes. - Maintenance Supervisor will test the alarms weekly and will be maintained according to manufacturer guideline. - A log of maintenance and testing will be kept by the Maintenance Supervisor The acceptable corrective action was verified with the facility to be implemented through observation, interview, and record review. The IJ was removed on October 17, 2024, at 2:46 PM, in the presence of the Administrator.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of eighteen residents (Resident 36) reviewed for advanced directives had a Physician Orders for Life Sustaining Treatment (POLST - written medical orders that addresses a limited number of critical medical decisions) accurately completed when there was conflicting information documented regarding medical interventions. This failure had the potential for Resident 36 to receive end of life care not in accordance with their wishes and for life sustaining measures to be rendered against what the resident wanted. Findings: During a review of Resident 36's admission Record, (contains medical and demographic information), the admission Record indicated Resident 36 was initially admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis on one side of the body) affecting left non-dominant side, heart failure, chronic respiratory failure (a long-term condition that prevents the body from exchanging oxygen and carbon dioxide properly), and Chronic Obstructive Pulmonary Disease (COPD - lung disease that causes breathing problems and restricted airflow). During a review of Resident 36's POLST, signed by a clinician on [DATE], the POLST indicated in Section A, Attempt Resuscitation/CPR [cardiopulmonary resuscitation - an emergency lifesaving procedure performed when the heart stops beating] . further review of Section A indicated, .selecting CPR in Section A requires selecting Full Treatment in Section B) .Section B of the POLST Medical Interventions, indicated two options; the first option was full treatment - Primary goal of prolonging life by all medically effective means .use intubation, advanced airway interventions, mechanical ventilation, and cardioversion as indicated . The second option was Selective Treatment - goal of treating medical conditions while avoiding burdensome measures .do not intubate .generally avoid intensive care . Of the two options, Selective Treatment was checked instead of Full Treatment as specified in Section A if Attempt/Resuscitation/CPR was selected. During a concurrent interview, and record review on [DATE], at 7:30 AM, with the Director of Nursing (DON), the DON stated if a resident wishes to have CPR/attempt resuscitation indicated in Section A of the POLST, then Section B must have full treatment checked as indicated on the instructions of the form. Resident 36's POLST was reviewed and the DON confirmed Attempt Resuscitation/CPR was checked in Section A and Section B had Selective Treatment selected. The DON stated Resident 36's POLST form needed to be clarified with the nurse who completed it. The DON further stated the POLST was supposed to be reviewed quarterly and upon admit for accuracy and completeness. The DON stated the POLST forms were important because it provides orders regarding what life sustaining treatments the resident desires. During an interview on [DATE], at 9:47 AM, with the Social Services Director (SSD), the SSD stated she was the one that completed the POLST for Resident 36, dated [DATE]. The SSD further stated she had the POLST revised by a physician today because it was not completed correctly. States the physician discussed with her the correct way to complete the POLST. During a review of the facility's policy and procedure (P&P) titled, Physician Orders for Life Sustaining Treatment (POLST), dated [DATE], the policy indicated, The physician Orders for Life-Sustaining Treatment (POLST) is a physician order form that complements an advance directive by converting an individual's wishes regarding life-sustaining treatment and resuscitation into physician orders. It is designed to be a statewide mechanism for an individual to communicate his or her wishes about a range of life-sustaining and resuscitative measures. It is designed to be portable, authoritative and immediately actionable physician order consistent with the individual's wishes and medical condition, which shall be honored across treatment settings .Completion of a POLST form should reflect a process of careful decision-making by the resident, or if the resident lacks decision-making capacity the resident's legally recognized health care decision maker, in consultation with the physician, about the resident's medical condition and known treatment preferences .Reviewing/Revising the POLST. 1. The POLST will be reviewed by the facility interdisciplinary team during the quarterly care planning conference .

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 ensure staff reported an allegation of abuse to the required parties and in the timelines specified by the facility's policy and procedures (P&P) and as required by federal regulations. This failure resulted in an allegation of abuse to not be reported and subsequently investigated which had the potential to place Residents 36 at risk for ongoing abuse or mistreatment due to a delay in the reporting and investigation of the alleged incident. Findings: A review of Resident 36's admission Record (contains medical and demographic information), indicated Resident 36 was initially admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis (weakness and paralysis) affecting left non-dominant side, heart failure, major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and anxiety disorder (a condition that causes excessive feelings of fear, dread, and worry that can interfere with daily life). During a concurrent observation and interview on October 14, 2024, at 3:00 PM, with Resident 36, Resident 36 was in her bed and was watching TV. Resident 36 stated staff would sometimes tell her she uses her call light too much and would take her call light away from her and put it where she couldn't see it or access it. During an interview on October 14, 2024, at 3:03 PM, with Resident 46 (roommate of Resident 36), Resident 46 stated she had seen staff tell Resident 36 that she uses the call light too much and take her call light away. During an interview on October 14, 2024, at 3:28 PM, with the Administrator (ADMIN), the ADMIN was informed by a surveyor regarding the allegation of abuse made by Resident 36. During an interview on October 17, 2024, at 6:41 PM, with Certified Nursing Assistant 6 (CNA 6), CNA 6 stated Resident 36 uses her call light ten to fifteen times throughout a shift and usually requires a lot of attention. CNA 6 further stated although she has not heard of Resident 36 having her call light taken away, she has heard of other residents who have told her that they had their call light taken away from them too. CNA 6 then stated she had informed her supervisor regarding the incident but could not remember who she informed. During an interview on October 17, 2024, at 7:06 PM, with Certified Nursing Assistant 7 (CNA 7), CNA 7 stated a resident had informed her in May of 2024, that a Certified Nursing Assistant working in the facility would take the residents call light away from them if the resident used the call light too much. CNA 7 stated she never reported the incident to anyone and only recalled mentioning it to another staff member but could not remember who. During an interview on October 18, 2024, at 9:22 AM, with the ADMIN, the ADMIN stated he was the facility's abuse prevention coordinator and has been so since July 1, 2021. The ADMIN further stated he had never in the past been informed of facility staff allegedly taking call lights away from residents. The ADMIN stated if staff suspected abuse or were made aware of an abuse allegation, they were supposed to report it to him immediately. During a review of the facility's P&P titled, Abuse Investigation and Reporting, (undated), the policy indicated, All reports of abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management .Reporting .1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative .d. law enforcement officials; e. The residents attending physician; and f. the facility medical director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24 hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury .

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** 2) During a review of Resident 11's admission Record (contains demographic and medical information), indicated Resident 11 was admitted to the facility on [DATE] with the medical diagnoses which included diabetes (a condition where the body can't control the blood sugar level in the body). During an observation on October 17, 2024, at 7:34 AM, Resident 11 was seating in the dining room eating her breakfast. During an observation on October 17, 2024 At 7:51 AM in the dining room, staff were observed moving Resident 11 from the dinning room to her room to administer her medications. The Director of Nursing (DON) who was assisting the night shift License Vocational Nurse 3 (LVN 3) prepared to give Resident 11 her medications. During a futher observation on October 17, 2024 At 7:51 AM, the DON checked Resident 11's blood sugar, but Resident 11 had already started eating her meal. During a review of Resident 11's Physician Orders dated February 13, 2023, indicated, Novolog Insulin Aspart (a type of insulin to used to treat high blood sugar) inject as per sliding scale: if 70-119=4 [units of insulin] hold if blood sugar is below 70; 120-300=7 units of insulin], subcutaneously (below the skin) before meals for diabetes. Resident 11's blood sugar was to be checked before meals. During an interview with the DON on October 17, 2024, at 7:55 AM, the DON acknowledged that Resident 11's blood sugar should have been checked before the breakfast meal and not after. During a review of Resident 11's care plan (an individualized plan for the medical care of a resident), titled At risk for hyperglycemia and hypoglycemia related to diagnosis of Type 2 Diabetes Mellitus, undated, the care plan indicated Resident 11 was at risk for hyperglycemia (elevated blood sugar) and hypoglycemia (low blood sugar), with the goal of having no complications related to diabetes, evidenced by the absence of signs or symptoms of hyperglycemia or hypoglycemia. The interventions included: Administering insulin subcutaneously for Diabetes Mellitus Type 2 as ordered by the physician . During a concurrent interview, and record review, on October 18 at 9:01 AM with the DON, the facility 's policy and procedure (P&P) titled, Insulin Administration, undated, was reviewed. The P&P indicated, 1. Check blood glucose per physician order or facility protocol. The DON stated the P&P was not followed and acknowledged that Resident 11's blood sugar should have been checked before meals. Based on observation, interview, and record review, the facility failed to ensure two residents (Residents 14 and 11) received care and services as specified In their care plans (individualized plans for the medical care of a resident) when: 1) For Resident 14, the facility did not ensure staff kept the resident's smoking materials. This failure had the potential to result in in accident or injury to Resident 14 and other residents residing in the facility as a result of increased fire hazard. 2) For Resident 11, the facility did not ensure staff checked the residents blood sugar before meals. This failure has the potential to affect Resident 11's blood sugar management and could lead to inaccurate blood sugar readings, which may result improper insulin administration (medication use in the treatment and management of diabetes) and increased risk of hyperglycemia (elevated blood sugar). Findings: 1) During a review of Resident 14's clinical record, the admission Record (contains medical and demographic information), indicated Resident 14 was admitted [DATE], with diagnoses which included Hemiplegia and hemiparesis (paralysis and weakness on one side of the body) on right dominant side, history of falls, and heart failure. During an interview on October 15, 2024, at 11:08 AM, with Resident 14, Resident 14 stated he was a smoker and kept his own smoking materials with him. During a concurrent observation, and interview, on October 17, 2024, at 4:09 PM, in Resident 14's room, with Resident 14, and in the presence of Certified Nursing Assistant 5 (CNA 5), Resident 14 was observed to have a nasal cannula (an oxygen delivery device) and was receiving oxygen. Resident 14 stated he kept his own smoking supplies in his bedside end table. CNA 5 opened Resident 14's bedside end table and there was one empty pack of cigarettes, another pack of cigarettes with 7 cigarettes left, and two lighters. During an interview on October 17, 2024, at 4:31 PM, with the Activities Director (AD), the AD stated staff were supposed to have Resident 14's smoking supplies and Resident 14 was not supposed to have any smoking supplies. During an interview on October 17, 2024, at 4:41 PM, with the Director of Nursing (DON), the DON stated Resident 14 was not supposed to keep his own smoking supplies and that the facility's practice was for staff to keep all smoking supplies. During a review of Resident 14's care plan titled, Resident is a smoker ., dated October 11, 2024, the care plan indicated, Interventions .Provide direct supervision to resident while smoking .smoking materials are to be kept by staff .Remove oxygen prior to smoking . During a review of Resident 14's Minimum data set (MDS - an assessment of a residents functional and health status), dated August 25, 2024, indicated Resident 14 had a Brief Interview for Mental Status score (BIMS score - a score of 0-15 used to determine cognitive functioning) of 12 (moderate cognitive impairment). During a review of Resident 14's Smoking Assessment-V1 (an assessment of the residents' level of risk associated with smoking), dated October 10, 2024, the assessment in section B. Cognitive indicated the resident was not able to recognize the smoking areas, and did not exhibit knowledge of the facility smoking rules. The Assessment section D. Current Tobacco Consumption per day, indicated the resident smoked 3-5 times a day. Section F. Safety, of the assessment indicated the resident was not able to hold, light and extinguish his own cigarettes, his personal items were not free from evidence of burn holes, the resident could not state or indicate that no smoking materials may be given to another resident and that the facility was to store the residents lighter and cigarettes. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy - Residents, (undated), the policy indicated, This facility has established and maintains safe resident smoking practices .11. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc. except under direct supervision .

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor and document the low air loss mattress (specialized mattress designed to help prevent and treat pressure ulcers) according to the physician's order for one of two sampled residents (Resident 40) who had a pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). This failure had the potential for Resident 40 not to receive the necessary treatment and services. Findings: A review of Resident 40's admission Record, (contains demographic and medical information), indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), and epilepsy (a disorder of the brain characterized by repeated seizures). During an observation on October 15, 2024, at 8:36 AM, Resident 40 was observed in her room, laying on her left side and asleep on a low air loss mattress bed. During a review of Resident 40's physician order, dated September 24, 2024, it indicated, Low Air Loss Mattress for tissue load management, check placement, setting, and monitor every shift. During a concurrent interview and record review on October 16, 2024, at 1:13 PM with the Treatment Nurse, Treatment Nurse stated Resident 40 has a stage 4 pressure ulcer (full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) opening on her coccyx. The physician's order and Treatment Administration Record (TAR-a document that tracks the time and type of treatments administered to a patient) for Resident 40 were reviewed. Treatment Nurse acknowledged there is a gap or missing documentation on the following dates and shift indicating monitoring of low air loss mattress bed was not completed: a. October 1, 2024, day, and eve shift b. October 2, 2024, night shift c. October 3, 2024, night shift d. October 4, 2024, eve shift e. October 6, 2024, eve shift f. October 7, 2024, eve shift g. October 9, 2024, eve shift h. October 11, 2024, eve shift i. October 12, 2024, eve shift j. October 13, 2024, eve, and night shift k. October 14, 2024, eve shift l. October 15, 2024, eve shift During a continued interview and observation with the Treatment Nurse, on October 16, 2024, at 1:14 PM, in Resident 40's room, Treatment Nurse demonstrated how she checks the low air mattress bed setting when she comes in every morning. She stated the low air mattress bed machine should be plugged in and set according to the red sticker. During an interview with the Licensed Vocational Nurse 1 (LVN 1) on October 17, 2024, at 9:19 AM, LVN 1 stated it is important to make sure Resident 40 is being repositioned. LVN 1 stated her, and the Treatment Nurse are responsible for monitoring low air loss mattress on day shift. She further stated it is important to check the settings of low air loss mattress because Resident's 40 main issue is her pressure ulcer. During a concurrent interview and record review on October 17, 2024, at 3:28 PM with Director of Nursing (DON), the Treatment administration record, for resident 40 was reviewed. The DON stated the nurse could have checked the low air mattress, and it could be just a documentation error. During a review of the care plan (an individualized plan for the medical care of a resident) for Resident 40, on October 17, 2024, at 6:29 PM, titled, At risk for skin breakdown related to history of pressure injury, immobility, Alzheimers, Dementia, Chronic Respiratory Failure, Bipolar disorder, dated September 24, 2024, the care plan interventions indicated Administer treatments as ordered and monitor for effectiveness. During a record review of the facility's policy and procedure titled, Pressure and Non-Pressure - Clinical Protocol, (undated), the policy indicated, Assessment and Recognition . 2. In addition, the nurse shall describe and document/report the following .d. Current treatments, including support surfaces

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to document a gradual dose reduction (GDR) for one of eight sampled residents (Resident 55) when a recommended a decrease in Trazadone (a medicine that helps people who are feeling very sad or having trouble to sleep) from 100 mg (milligrams unit of measurement) to 50 mg was not done and documented. This failure has the potential to result in over medication and increased risk of side effects for Resident 55. Finding: During a review of Resident 55's admission Record (contains demographic and medical information), indicated Resident 55 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (a mental health condition characterized by persistent sadness and loss of interest), and bipolar disorder (a mental health condition where a person has extreme mood swings). During a review of Resident 55's pharmacist's recommendation dated October 7, 2024, indicated a recommended GDR of Trazadone dose from 100 mg to 50 mg due to the Resident 55's stable condition. During a review of Resident 55's physician orders for October 2024, there is no documented evidence Trazadone has been decreased from 100 mg to 50 mg. Further review of Resident 55's physician's orders indicated Resident 55 has been receiving trazadone 100 mg since June 5, 2024. During a review of Resident 55's care plan (an individualized plan for the medical care of the resident) titled, Depression Management, undated, the care plan indicated Resident 55 had episodes of depression manifested by inability to sleep. The goal was to minimize the risk of adverse side effects of medication usage, including Trazadone, through appropriate interventions. The interventions included administer antidepressant medication as per physician's order, monitor and record episodes of behavior per psychotropic policy .Gradual Dose Reduction (GDR) as indicated . During a review of the Resident 55's Nurse Practitioner's (NP) Progress notes dated October 7, 2024, the NP progress notes indicated Resident 55 had been evaluated and was found to be stable. A GDR for Trazodone was recommended reducing the dose from 100 mg to 50 mg. Further review of NP's progress notes dated October 7, 2024; it indicated Resident 55 had agreed to the GDR during the NP's evaluation. During an observation, and interview, with Resident 55's on October 17, 2024, at 2:29 PM, Resident 55 was observed lying down on her bed with her eyes open and able to verbalize her needs. Resident 55 agree to be interviewed and she was aware she had been taking Trazadone 100 mg at night because it helps her sleep. Resident 55 expressed that she wanted to continue taking this dose. During an interview on October 15, 2024, at 5:16 PM with Director of Nurses (DON), the DON confirmed that Resident 55 was still taking Trazodone 100 mg per the physician's orders. The DON further explained that she had attempted to obtain Resident 55's consent for the dose reduction, but Resident 55 refused, expressing her preference to continue with the Trazadone 100 mg dose. The DON further stated that she notified the Nurse Practitioner (NP) of Resident 55's decision to continue with Trazadone 100 mg but acknowledged that she forgotten to document both Resident 55's refusal of GDR and the communication with the NP. The DON agreed this was a discrepancy in her documentation and that it should have been recorded. During an interview on October 18, 2024, at 9:07 AM, with the DON, the facility's policy, and procedure (P&P) titled, Nursing Documentation dated December 2023, was reviewed. The P&P indicated, 3. Refusal of treatments: Documentation pertaining to resident refusal of treatment should include: A. the date and time the treatment was attempted. B. The treatment attempted .D. Documentation that the resident was informed of the purpose of the treatment and the consequences of not receiving the care . The DON acknowledged the P&P was not followed and agreed Resident 55's refusal of the GDR and the communication with NP should have been documented.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) for labeling and dating of food items when a bottle of [brand name] creamer was found on top of a table inside the kitchen at room temperature without an open date. This failure has the potential to increase the risk of foodborne illness or contamination due to improper storage practices. Finding: During an observation on October 14, 2024, at 8:16 AM, during a tour inside the kitchen area, a bottle of [brand name] coffee creamer was observed on top of a table inside the kitchen area. The bottle was open and halfway already used, and there was no open date written on the bottle to indicate when it was first opened. During an interview on October 14, 2024, at 8:18 AM, with the Dietary Services Supervisor, (DSS 1), the DSS 1 confirmed that the creamer was found open, used and unlabeled. The DSS 1 stated that the bottle of creamer should be labeled and properly stored according to facility's P&P. The DSS 1 further stated that the bottle of creamer will be dispose immediately. During a concurrent interview, and record review, on October 18, 2024, at 8:50 AM, with the DSS 1, the facility's P&P titled, Labeling and dating of foods dated 2023, was reviewed. The P&P indicated, All food items in the store room, refrigerator, and freezer need to be labeled and dated .Procedure: Newly opened food items will need to be closed and labeled with an open date and used by the date that follows the various storage guidelines .

CONCERN (D)

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

Deficiency F0912 (Tag F0912)

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 of 46 resident's rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to limit freedom of movement and affect the health and safety of four residents (Resident 55, 28, 64, and 44) who reside in the two rooms. Findings: During an interview with the Administrator (ADMIN) on October 17, 2024 at 8:11 AM, the ADMIN stated the facility has two rooms with square footage waivers, rooms [ROOM NUMBERS]. The ADMIN further stated the facility submitted a room waiver variance sometime within the last week. During concurrent observations, and interviews with the residents (55 and 28) in room [ROOM NUMBER], on October 17, 2024 at 8:13 AM the following were observed: Bed 7A was occupied by Resident 55, who was observed resting comfortably in bed. Resident 55 did not verbalize any issues or concerns with the size of the room. There were no concerns with the beds, bedside tables, and wheelchairs which are accessible to the room. Bed 7B was occupied by Resident 28, who was observed resting comfortably in bed. Resident 28 did not verbalize any issues or concerns with the size of the room. There were no concerns with the beds, bedside tables, and wheelchairs which are accessible to the room. During concurrent observations, and interviews with the residents (Resident 64 and 44) in room [ROOM NUMBER], on October 17, 2024, at 8:19 AM, the following were observed: Bed 11A was occupied by Resident 64, who was observed in the room. Resident 64 did not verbalize any issues or concerns with the size room. There were no concerns with the beds, bedside tables, and wheelchairs which are accessible to the room. Bed 11B was occupied by Resident 44, who was observed in the room. Resident 44 did not verbalize any issues or concerns with the room. There were no concerns with the beds, bedside tables, and wheelchairs which are accessible to the room. During an environmental tour of rooms [ROOM NUMBERS], with the Maintenance Director on October 17, 2024 at 8:13 AM, the following measurements were noted as follows: 1. room [ROOM NUMBER] measured 12 feet 10 inches x 11 feet 4 inches = 145.43 square feet total (72.7 square feet per resident)room [ROOM NUMBER] did not have the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. 2. room [ROOM NUMBER] measured 12 feet 9 inches x 11 feet 2 inches = 142.61 square feet total (71.3 square feet per resident)room [ROOM NUMBER] did not have the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. During the course of the survey, rooms [ROOM NUMBERS] were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms.

CONCERN (E)

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

Deficiency F0638 (Tag F0638)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. During a review of Resident 27's admission Record, the admission Record indicated Resident 27 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), and cerebral ischemia (occurs when the brain doesn't receive enough blood flow or oxygen). During an interview with Resource MDS Nurse (RMN), on October 17, 2024, at 10:22 AM, RMN stated that current Minimum Data Set Nurse (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA) is out of the country due to a family emergency. RMN checked Resident 27's quarterly assessment that was done on August and MDS was transmitted for completion on October 10, 2024. He stated that he does not know why it was not turned in on time. During a continued interview and record review with RMN on October 17, 2024, at 11:25 AM, a clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, for Resident 27 was reviewed. MDS quarterly assessment record and Assessment Reference Date (ARD- specific end point of look-back periods in the MDS assessment process) date was on August 19, 2024, but it was completed on October 10,2024, which was 52 days past the ARD. He stated that he does not know why it was not turned in on time. D. During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was admitted to the facility on [DATE], with diagnoses which included ( diabetes (condition that happens when your blood sugar is too high), hypertensive heart disease (problems with your heart that can develop if you have high blood pressure), and osteoarthritis (a chronic degenerative joint disease that occurs when the cartilage in a joint break down and becomes rough). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 15's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 15's MDS quarterly assessment record and (ARD) was on September 9, 2024, but it was completed on October 12,2024, which was 33 days past the ARD. He stated that he does not know why it was not turned in on time. E. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was 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), atherosclerosis of aorta (condition where plaque builds up in the walls of the aorta, the body's largest artery), and anxiety disorder (a condition that causes excessive worry and fear that can interfere with daily life). During a concurrent interview and record review on October 17. 2024, at 11:53 AM, with RMN, Resident 35's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 35's MDS quarterly assessment record and ARD was on September 9, 2024, but it was completed on October 14,2024, which was 35 days past the ARD. He stated that he does not know why it was not turned in on time. F. During a review of Resident 40's admission Record, the admission Record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities), chronic respiratory failure (a long-term condition that makes it difficult for the body to exchange oxygen), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and epilepsy (a disorder of the brain characterized by repeated seizures). During a concurrent interview and record review on October 17,2024, at 11:53 AM, with RMN, Resident 40's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 40's MDS quarterly assessment record and ARD was on September 6, 2024, but it was completed on October 12,2024, which was 36 days past the ARD. He stated that he does not know why it was not turned in on time. G. During a review of Resident 47's admission Record, the admission Record indicated Resident 47 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), chronic respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in your body), hypertensive heart disease (problems with your heart that can develop if you have high blood pressure), and anxiety disorder (a condition that causes excessive worry and fear that can interfere with daily life). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 47's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 47's MDS quarterly assessment record ARD was on September 6, 2024, but it was completed on October 12,2024, which was 36 days past the ARD. He stated that he does not know why it was not turned in on time. H. During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE], with diagnoses which included atherosclerotic heart disease (a condition where plaque builds up in the arteries of the heart), hypertensive heart disease (problems with your heart that can develop if you have high blood pressure), dementia (a progressive state of decline in mental abilities), and anxiety disorder (a condition that causes excessive worry and fear that can interfere with daily life). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 49's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 49's MDS quarterly assessment record and ARD was on August 30, 2024, but it was completed on October 12,2024, which was 43 days past the ARD. He stated that he does not know why it was not turned in on time. I. During a review of Resident 51's admission Record, the admission Record indicated Resident 51 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), chronic respiratory failure (condition where there's not enough oxygen or too much carbon dioxide in your body), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a concurrent interview and record review on October 17, 2024, at 11: 53 AM, with RMN, Resident 51's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 51's MDS quarterly assessment record and ARD was on September 6, 2024, but it was completed on October 12,2024, which was 36 days past the ARD. He stated that he does not know why it was not turned in on time. J. During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was admitted to the facility on [DATE], with diagnoses which included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia (a progressive state of decline in mental abilities), and diabetes (condition that happens when your blood sugar is too high). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 62's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 62's MDS quarterly assessment record and ARD was on August 24, 2024, but it was completed on October 10,2024, which was 47 days past the ARD. He stated that he does not know why it was not turned in on time. K. During a review of Resident 63's admission Record, the admission Record indicated Resident 63 was admitted to the facility on [DATE], with diagnoses which included atherosclerotic heart disease (a buildup of fats, cholesterol and other substances in and on the artery walls), schizophrenia (a mental illness that is characterized by disturbances in thought), and Hodgkin lymphoma (a type of cancer that develops in the lymph system). During a concurrent interview and record review on October 17, 2024, at 11: 53 AM, with RMN, Resident 63's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 63's MDS quarterly assessment record and ARD was on August 31, 2024, but it was completed on October 12,2024, which was 42 days past the ARD. He stated that he does not know why it was not turned in on time. L. During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), diabetes (condition that happens when your blood sugar is too high), hypertensive heart disease (disease (problems with your heart that can develop if you have high blood pressure), and hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). During a concurrent interview and record review on October 17, 2024, at 11:53 AM, with RMN, Resident 66's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 66's MDS quarterly assessment record and ARD was on August 26, 2024, but it was completed on October 12,2024, which was 47 days past the ARD. He stated that he does not know why it was not turned in on time. M. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was admitted to the facility on [DATE], with diagnoses which included fracture (a break in a bone) of right lower leg, and diabetes (high blood sugar). During a concurrent interview and record review on October 17,2024, at 11: 53 AM, with RMN, of Resident 76's clinical record titled, Centers for Medicare and Medicaid Services (CMS) Submission Report, was reviewed. Resident 76's MDS quarterly assessment record and ARD was on September 6, 2024, but it was completed on October 10,2024, which was 34 days past the ARD. He stated that he does not know why it was not turned in on time. During an interview with the Director of Nursing (DON) on October 17, 2024, at 3:51 PM, the DON stated the facility did not have a policy and procedure (P&P) regarding completion of the MDS assessments and the facility follows the guidelines from the RAI (Resident Assessment Instrument - helps gather definitive information on a resident's strengths and needs) manual. DON acknowledged that quarterly assessments were not submitted on time. She further stated that they don't have MDS nurse because previous MDS nurse left early of September of this year and current MDS nurse is on leave. During a review of CMS Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2023, version 1.18.11, the manual indicated on pages 2-35, indicated, The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act of 1987) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. As such, not all MDS items appear on the Quarterly assessment. The ARD (A2300) must be not more than 92 days after the ARD of the most recent OBRA assessment of any type. Based on interview, and record review, the facility failed to ensure a Minimum Data Set (MDS- a facility assessment tool that consists of the resident assessment instrument (RAI) and the care area assessment (CAA) was conducted and submitted to the Centers of Medicare and Medicaid Services (CMS) in accordance with federal submission timeframes, for thirteen of thirteen residents (Residents 54, 55, 15, 27, 35, 40, 47, 49, 51, 62, 63, 66, and 76) reviewed for residents' assessment. These failures resulted in inadequate monitoring of progress or decline for Residents 54, 55, 15, 27, 35, 40, 47, 49, 51, 62, 63, 66, and 76 and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: A. During a review of Resident 54's admission Record, (contains demographic and medical information), the admission Record, indicated Resident 54 was admitted to the facility on [DATE], with diagnoses which included dementia (a progressive state of decline in mental abilities), psychosis (a mental disorder characterized by a disconnection from reality), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (high blood pressure). During a review of Resident 54's Electronic Health Record (EHR), a quarterly MDS assessment with an ARD (specific end point of look-back periods in the MDS assessment process) date of September 7, 2024, indicated it was completed on October 10, 2024 (33 days past the ARD). During a concurrent interview and record review on October 17, 2024, at 9:47 AM, with the Resource MDS Nurse (RMN), Resident 54's MDS assessment dated [DATE], was reviewed. The RMN stated the quarterly MDS assessment dated [DATE], was supposed to be completed within 14 days of September 7, 2024, but it was not completed until October 10, 2024. The RMN further stated he did not know why it was completed late. During an interview on October 17, 2024, at 9:52 AM, with the Director of Nursing (DON), the DON stated MDS assessments were supposed to be done on time but the facility had been having difficulties filling the MDS nurse (a nurse whose primary responsibility is to perform MDS assessments and related tasks) position because the previous MDS nurse left the company and the new MDS nurse is on leave. B. During a review of Resident 55's admission Record, the admission Record, indicated Resident 55 was admitted to the facility on [DATE], with diagnoses which included schizophrenia (a mental illness that is characterized by disturbances in thought), anxiety disorder (a condition that causes excessive worry and fear that can interfere with daily life), major depressive disorder and Chronic Obstructive Pulmonary Disease (COPD-a chronic lung disease causing difficulty in breathing). During a review of Resident 55's Electronic Health Record (EHR), an MDS assessment with an ARD (specific end point of look-back periods in the MDS assessment process) date of September 7, 2024, indicated it was completed on October 11, 2024 (34 days past the ARD). During a concurrent interview and record review on October 17, 2024, at 9:45 AM, with the RMN, Resident 55's MDS assessment dated [DATE], was reviewed. The RMN stated the quarterly MDS assessment dated [DATE], was supposed to be completed within 14 days of September 7, 2024, but it was not completed until October 11, 2024. The RMN further stated he did not know why it was completed late.

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow a system for controlling the spread of a communicable disease for one of four sampled residents (Resident 1) when Resident 1 was on transmission-based droplet precautions (a set of measures used to prevent the spread of organisms that cause disease through respiratory secretions) for a coronavirus disease (COVID-19-an infectious disease caused by a virus) exposure and was allowed to participate in activities with 11 other residents. This failure had the potential to cause the spread of COVID-19 to other residents in the facility. Findings: A review of Resident 1 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of March 8, 2024. Resident 1 had diagnoses that included dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 5 ' s face sheet (a document that gives a summary of resident ' s information), undated, indicated an admission date of February 22, 2024. Resident 5 had diagnoses that included Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, eventually making it difficult to perform basic tasks). A review of Resident 5 ' s COVID-19 laboratory test dated September 18, 2024, indicated, Results: positive and symptomatic. A review of Resident 1 ' s care plan dated September 18, 2024, indicated, Focus: [Resident 1] with COVID-19 exposure. Date Initiated: [September 18, 2024] Revision on: [September 18, 2024]. Goal: Prevent the spread of COVID-19 in the facility Date Initiated: [September 18, 2024] Target Date: [October 2, 2024]. Interventions: Encourage/Remind Resident to wear mask and maintain social distancing. Date Initiated: [September 18, 2024] . Initiate transmission-based precaution (DROPLET). Staff to implement full PPE [Personal Protective Equipment] use (mask, face shield/goggles, gown, gloves) when providing direct care to the resident. Date Initiated: [September 18, 2024] Keep the number of staff assigned to enter the room at a minimum and staff to bundle resident care activity. Date Initiated: [September 18, 2024] Educate resident and provide information regarding COVID-19. Date Initiated: [September 18, 2024] Promote social distancing; and avoid communal dining/group activities. Provide means of communication/engagement with family members, resident representatives and/or friends while visitation is restricted. Provide individualized activities of choice. Date Initiated: [September 18, 2024] . During an observation on September 23, 2024, at 1:34 PM, arrived at Resident 1 and Resident 5's room. The room's door was closed, and an Isolation Precautions-Droplet sign was posted. PPE was available outside the door: N95 mask (a respiratory protective device), face shield, gown and gloves. The Surveyor performed hand hygiene and donned (put on) the PPE. The Surveyor knocked on the door and entered the room. Resident 5 was sitting on the bed closest to the door. The Surveyor introduced herself to Resident 5 and asked how she was feeling. Resident 5 looked at the Surveyor but did not respond. Resident 1's bed farthest from the door was empty. The Surveyor looked around the room and in the adjoining bathroom but Resident 1 was nowhere to be found. The Surveyor doffed (took off) her PPE, performed hand hygiene and left the room. During an observation and interview with Resident 1 and an Infection Preventionist Nurse (IP Nurse) on September 23, 2024, at 1:40 PM, Resident 1 was in the dining room, seated at a table and working on a word search activity. The dining room held eleven other residents and one activity staff member. All the residents were engaged in a variety of tabletop activities. Resident 1 was wearing a short sleeve shirt, long pants, and socks, but no face mask. Resident 1 was clean and well groomed; no injuries were visualized. Resident 1 did not appear to be in distress. The IP Nurse confirmed Resident 1 was not wearing a mask and was participating in activities with eleven other residents, in a common area. The IP Nurse confirmed Resident 1 shared a room with Resident 5 who had tested positive for COVID-19 and had displayed symptoms. The IP Nurse confirmed Resident 1 resided in a room placed on Isolation Precautions-Droplet because she had been exposed to COVID-19 by Resident 5. The IP Nurse stated Resident 1 refused to wear a mask and was allowed to come and go from her isolation room. During an interview with the Director of Nursing on September 23, 2024, at 3 PM, The DON confirmed Resident 1 was on Isolation Precautions-Droplet for a COVID-19 exposure. The DON confirmed Resident 1's care plan indicated Encourage/Remind Resident to wear mask and maintain social distancing. Promote social distancing; and avoid communal dining/group activities. Provide means of communication/engagement with family members, resident representatives and/or friends while visitation is restricted. Provide individualized activities of choice. The DON stated Resident 1's care plan was not followed. The DON stated it was the facility's responsibility to minimize the spread of COVID-19 to other residents. A review of the facility ' s policy and procedure titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, undated, indicated, Policy Statement: This facility follows infection prevention and control (IPC) practices recommended by the Centers for Disease Control and Prevention to prevent the transmission of COVID-19 within the facility. Policy Interpretation and Implementation: . f. implementing source control measures.

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe environment for two of three sampled residents (Residents 1 and 3) when: 1. Resident 1 ' s call light was found hanging from a light fixture on a wall. 2. Resident 3 ' s call light was found behind a nightstand on the floor. These failures had the potential to result in resident harm and unmet needs for Residents 1 and 3. Findings: 1. During a review of Resident 1 ' s admission Record (contains demographic and medical information), the admission record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (a condition where a person experiences a decline in their memory, thinking and reasoning skills), unsteadiness on feet, and repeated falls. During a concurrent observation and interview, on March 12, 2024, at 10:19 AM, with Resident 1, in her room, Resident 1 ' s call light was hanging from the light fixture on the wall, inaccessible. Resident 1 stated she did not know where the call light was. Resident 1 further stated she needed to use the restroom. During a concurrent observation and interview, on March 12, 2024, at 10:20 AM, with the Director of Staff Development (DSD) and a Certified Nurse Assistance (CNA 1), in Resident 1 ' s room, the DSD and CNA 1 acknowledge Resident 1 ' s call light was not within reach and should have been. 2. During a review of Resident ' s 3 admission Record indicated Resident 3 was admitting on December 6, 2020, with diagnoses of dementia (condition where a person experiences a decline in their memory, thinking and reasoning skills), peripheral vascular disease (condition that affects the blood circulation in their body), and respiratory failure (when the lungs can ' t provide enough oxygen to the body.). During an observation, on March 12, 2024, at 10:19 AM, at Resident 3's room, Resident 3 was lying down in bed with her eyes closed. Residents 3 ' s call light was found on the floor, inaccessible. During a concurrent observation and phone interview, on March 12, 2024, at 10:24 AM, with the DSD and CNA 1, in Resident 3 ' s room, the DSD and CNA 1 acknowledge that Resident 3 ' s call light was behind the nightstand on the floor, and stated the call light should be within the resident ' s reach. During a concurrent phone interview and record review, on April 9, 2024, at 2:16 PM, the Administrator (Admin) reviewed the facility ' s policy and procedure (P&P) titled, Answering the Call Lights, dated September 2022, which indicated .5. Ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and form the floor . The Admin stated the policy was not followed.

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their policy and procedures for Fall Risk Assessment for one of three sampled residents (Resident 1) when Resident 1 was not accurately assessed for fall risk. This failure resulted in Resident 1 to experience a fall. Findings: An unannounced visit was made to the facility on November 30, 2023, at 5:30 PM, to investigate a Facility Reported Incident (FRI) regarding quality of care/treatment. During an observation on November 30, 2023, at 5:35 PM, in Resident 1's room, Resident 1 was lying down on her bed on her back, with head of the bed elevated. Resident 1 had a bandage wrapped around her leg and heel protector on feet. During an interview on November 30, 2023, at 5:45 PM, in Resident 1's room, Resident 1 stated she did not remember when she had a fall. During a review of Resident 1's face sheet (a document which contain basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE], with diagnosis which include cerebral infarction (stroke), Glaucoma (a disease of the eyes which causes blindness) and osteoporosis (a bone disease which causes brittle bones). During a review of Resident 1's History and physical (H&P) dated June 16, 2023, indicated Resident 1 has a history of falls, and history of compression fracture vertebra (a broken bone that cause the back to collapse, making them shorter). Further Review of Resident 1's H&P dated June 16, 2023, indictated Resident 1 can make decisions. During a review of Resident 1's Fall Risk Assessment dated October 18, 2023, indicated, Score 9, category: Low Risk . Further review of the Resident 1's Fall Risk Assessment dated October 18, 2023, indicated under section, 4. Vision, Resident 1's vision was adequate. Further review of the Resident 1's Fall Risk Assessment dated October 18, 2023, indicate under section, 7. Medications indicated Resident 1 was taking 1- 2 of these medications currently and /or within last 7 days. Further review of the Resident 1's Fall Risk Assessment dated October 18, 2023, indicated under section 9 predisposing diseases indicated Resident 1 had 1 to 2 present. During a telephone interview with Director of Staff Development 2 (DSD 2) on December 13, 2023, at 2:30 PM, DSD 2 stated, the Fall Risk Assessment dated October 18, 2023, was inaccurate. DSD 2 further stated there was a discrepancy on sections 4. VISION STATUS. DSD 2 stated Resident 1 had a diagnose of Glaucoma and it should have been noted. DSD further stated there was a discrepancy on Section 7 MEDICATIONS. DSD 2 stated Resident 1 was taking two blood pressure medications and one nacrotic and it should have been noted. DSD 2 stated there was a discrepancy on Section 9. PRESDISPOSING DISEASE. DSD 2 stated Resident 1 had diagnosis of CVA, Osteoporosis and History of compression fracture and should have been noted. The DSD 2 stated Resident 1's Fall Risk Assessment the score should had been higher than 9, which would have indicated Resident 1 was a high risk for falls. During an interview with DSD 2 conducted via phone on December 14, 2023, at 2:32, DSD stated, that Resident 1, should had been place on a fall prevention program prior the fall but that Resident 1's was not place in the fall prevention program until after the fall. During a review of the policy and procedure titled, Fall Risk Assessment, undated, indicated, The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. Further review of the policy and Procedure indicated, 1.Upon admission, the nursing staff and the physician will review a resident's record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. 2.The nursing staff will ask the resident and/or his/her family about any history of the resident falling. 3.The nursing staff, attending physician, and consultant pharmacist will review for medications or medication combinations that could relate to falls or fall risk, such as those that have side effects of dizziness, ataxia, or hypotension. 4.The staff will look for evidence of a possible link between the onset of falling (or an increase in falling episodes) and recent changes in the current medication regimen. 5.The attending physician and nursing staff will evaluate the resident's vital signs, assess the resident for medical conditions (such as those that cause dizziness or vertigo) or sensory impairments (such as de-creased vision and peripheral neuropathy) that may predispose to falls. 6.Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls (such as osteoporosis).

Sept 2023 1 deficiency 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

Accident Prevention (Tag F0689)

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 on one (1:1) supervision (direct one on one monitoring of a resident by a staff member) was implemented for one of 80 residents (Resident 1) as ordered by a physician on April 13, 2023 when Resident 1 was found on the floor of his room with his door closed and unaccompanied by staff with a laceration (a cut or skin wound) injury to his head after he sustained an unwitnessed fall. This failure resulted in Resident 1 sustaining a head injury which required treatment and evaluation in a hospital. Findings: During a review of Resident 1 ' s clinical record, the admission Record (contains demographic and medical information), indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses which included diffuse traumatic brain injury (head injury), dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning), unsteadiness on feet, epilepsy (a brain disorder that causes recurring seizures), schizoaffective disorder (a disorder characterized by a combination of hallucinations or delusions, and mood disorder symptoms such as depression or mania) and altered mental status (altered state of mental functioning). During a review of Resident 1 ' s Minimum Data Set ( MDS - an assessment of the resident ' s functional and health status), dated April 10, 2023, the MDS indicated Resident 1 had a severely impaired mental status according to the Brief Interview for Mental Status (BIMS – a screening tool used to determine mental status; A score of 13 to 15 suggests the patient is cognitively (the ability of the brain to think and reason) intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment). Resident 1 scored a 4 (severely impaired). During a review of Resident 1 ' s Fall Risk Assessment dated April 13, 2023, the assessment indicated the resident was at High Risk for falls and had sustained .3 or more falls in past 3 months. During a review of Resident 1 ' s Initial Psychiatric Evaluation dated April 11, 2023, indicated, .Treatment Plan: .-Staff will assure the client of safety .Resident on monitoring for increased aggressive behavior and recent falls . During a concurrent interview and record review on August 23, 2023, at 11:26 AM, the DON provided an untitled document which listed incidents when Resident 1 fell in the facility for the month of April 2023. The untitled document dated April 1, 2023, through April 30, 2023, indicated Resident 1 had fallen three times in the month of April 2023 (April 7, 2023, April 9, 2023, and April 13, 2023). During a review of Resident 1 ' s physician ' s orders, an order dated April 10, 2023, indicated, 1:1 [one on one] monitoring by CNA [Certified Nursing Assistant]. During a telephone interview on August 8, 2023, at 4:48 PM with Certified Nursing Assistant 1, CNA 1 stated he worked at the facility [name of facility] on April 13, 2023, when Resident 1 fell and sustained a head injury and had to be sent to the hospital. CNA 1 stated Resident 1 was one of the residents assigned to him during his shift. CNA 1 stated he could not remember which Licensed Vocational Nurse (LVN) but stated an LVN told him that he was on a 1:1 (one to one) assignment with Resident 1 and that he needed to keep checking in on Resident 1 throughout his shift. CNA 1 stated he was also responsible to help other residents throughout his shift even though he was assigned 1:1 with Resident 1. CNA 1 stated when Resident 1 fell on April 13, 2023, the resident was in his room with the door closed and was not accompanied by any staff members inside the room. CNA 1 stated at the time Resident 1 fell, he (CNA 1) was outside the Resident 1 ' s room and was attempting to redirect another resident who was trying to open Resident 1 ' s door. CNA 1 stated he did not want Resident 1 to be woken up and that ' s when he heard Resident 1 yell and as he opened the door and entered the room, he found Resident 1 had fallen and hit the back of his head on the floor and was bleeding. CNA 1 further stated he was the first to respond to the fall. During an interview on August 16, 2023, at 12:15 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated she was working at the facility [name of facility] on April 13, 2023, when Resident 1 fell during her shift. LVN 1 stated CNA 1 was assigned to do 1:1 monitoring with Resident 1 that day and when Resident 1 fell, CNA 1 was outside the door of Resident 1 ' s room. LVN 1 further stated Resident 1 required 1:1 monitoring due to his history of falls and stated Resident 1 was unsteady on his feet. During an interview on August 16, 2023, at 4:15 PM, with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated he was working at the facility on April 13, 2023, when Resident 1 fell. CNA 2 stated CNA 1 was assigned to do 1:1 with Resident 1 because Resident 1 kept getting up all the time and had a history of falls. CNA 2 stated throughout his shift, he saw CNA 1 outside Resident 1 ' s room with the door closed on multiple occasions (could not quantify how many times). CNA 2 further stated when he saw CNA 1 outside Resident 1 ' s room, he (CNA 1) was just standing there and sometimes talking to staff but was not performing any particular tasks. CNA 2 further stated on other occasions when he saw other staff members assigned to 1:1 monitoring, they were in the room with Resident 1 and not outside the room with the door closed, but stated this time was different. During an interview on August 23, 2023, at 9:20 AM, with the Director of Nursing (DON), the DON stated Resident 1 had behaviors and would at times be unsteady on his feet and had physician orders for 1:1 (one on one) supervision. The DON stated her expectation was that if a staff member was assigned to do 1:1 (one on one) with a resident, they should always be in the room with the resident. The DON further stated any staff assigned to do 1:1 monitoring of a resident should be next to the resident or near them and in the line of sight of the resident at all times. The DON stated it would be unacceptable for a staff member to be outside a room of a resident on 1:1 monitoring with the door closed. The DON stated 1:1 monitoring is important for the safety of the resident and other residents within the facility. During a concurrent interview and record review, on August 23, 2023, at 9:46 AM, with the DON, the written statement from CNA 1, dated April 13, 2023, was reviewed. The statement indicated, I, [name of CNA 1] making a statement about [name of Resident 1] ' s fall incident. I was assigned to do one on one with [name of Resident 1]. Around 7:20 PM I was redirecting another patient not to get in into [sic] [name of Resident 1] ' s room because I don ' t [sic] want the patient to be disturbed onto [sic] his sleep. I heard [name of Resident 1] yelled and I immediately came up to him and I found him laying [sic] on the floor . The DON stated, Reading the statement from the CNA, it sounds as though it was an unwitnessed fall. The DON further stated it would have been unacceptable if the staff member was outside of the room of a resident with the door closed while on 1:1 monitoring. The DON further stated if the door is closed, the staff should be inside the room with the resident. During an interview on August 23, 2023, at 4:00 PM, with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated she worked on April 13, 2023, when Resident 1 fell. CNA 3 stated she recalled seeing CNA 1 assigned to do 1:1 supervision for Resident 1 and stated she saw CNA 1 sitting in a chair outside Resident 1 ' s room on multiple occasions while the resident was in the room with the door closed. During a review of Resident 1 ' s document titled, [name of hospital] .ED [emergency department] Provider Report . dated 4/13/23, the document indicated, [name of Resident 1] .History of Present Illness .Fall Injury .62 y/o [year old] male .BIBA [brought in by ambulance] from [name of facility] after sustaining an unwitnessed fall today. Per EMS [emergency medical services] pt was noted to have a hematoma [a collection or pooling of blood outside a blood vessel] to the back of his head .he's had a total of 3 falls this week .CT [computated tomography- an imaging procedure that uses a combination of x-rays and computer technology to produce images of the inside of the body] scanning .Impression: Small posterior right parafalcine and tentorial subdural hemorrhage [bleeding in the posterior (rear) aspect of the brain], 3 mm [Millimeters - a unit of measure] in thickness .Posterior scalp 3 cm [centimeters - a unit of measure] partial-thickness laceration .3 staples placed without incident .Diagnosis: Altered mental status fall, close head injury, scalp laceration, subdural hemorrhage .Condition: Critical . During a review of the facility ' s policy and procedure titled, Falls and Fall Risk, Managing, revised March 2018, the policy indicated, .Resident conditions that may contribute to the risk of falls include: .c. Delirium [a mental state in which you are confused, disoriented, and not able to think or remember clearly] and other cognitive impairment; .i. functional impairments . 3. Medical factors that contribute to the risk of falls include: .e. balance and gait [manner of walking] disorders .Resident-Centered Approaches to Managing Falls and Fall risk 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. During a concurrent interview and record review on August 23, 2023, at 10:18 AM, with the DON, the facility ' s policy and procedure titled, Safety and Supervision of Residents, (undated), the policy indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .4. Implementing interventions to reduce accident risks and hazards shall include the following routine checks of resident or 1:1 supervisions to ensure safety .d. ensuring that interventions are implemented; and e. Documenting interventions. 5. Monitoring the effectiveness of interventions shall include the following: a. Ensuring that interventions are implemented correctly and consistently; . The DON stated the policy was not followed. During an interview on August 14, 14, 2023, at 4:05 PM, with the DON, the DON stated the facility did not have a policy and procedure regarding 1:1 supervision.

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0583 (Tag F0583)

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 maintain the privacy of one of 86 residents (Resident 1) who resided within the facility when a staff member recorded a video of Resident 1 (while inside the facility's dining room) and posted the video on a personal social media platform without Resident 1's approval or consent. This failure resulted in a violation of Resident 1's right to privacy and confidentiality as well as a breach of the Health Insurance Portability and Accountability Act law (HIPPA -a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient's consent or knowledge). Findings: During a review of Resident 1's admission Record (contains Resident 1's medical and demographic information), undated, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning); Schizoaffective disorder, depressive type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression); Anxiety disorder (mental illnesses that causes constant and overwhelming anxiety and fear); restlessness and agitation. During an interview on May 31, 2023, at 3:26 PM, with the Case Manager 1 (CM 1), CM 1 stated on May 22, 2023, she received a call from a former employee (Licensed Vocational Nurse 1 - LVN 1) who wanted to notify her that there was a video of Resident 1 recorded from within the facility's dining room and posted on the social media platform [name of social media]. CM 1 stated LVN 1 sent her the video and she (CM 1) was able to identify Resident 1, and Certified Nursing Assistant 1 in the video because she could see their faces. CM 1 stated the video recording showed Resident 1 and CNA 1 while in the facility's dining room and the video showed Resident 1 flipping someone off across the room. CM 1 then stated she could see from the video that it was from the social media platform [name of social media] and that it was posted to the social media account of Certified Nursing Assistant 2 (CNA 2). CM 1 stated she forwarded the video to the facility's Administrator (ADMIN). During an interview on June 27, 2023, at 10:50 AM, with ADMIN, the ADMIN stated CM 1 brought to his attention that employee CNA 2 had posted a video of Resident 1 to her (CNA 2's) social media account and that the video was taken from within the facility. The ADMIN further stated when he reviewed the video he could see Resident 1 and CNA 1 in the video who were both flipping off someone while in the facility's dining room. The ADMIN stated the video was approximately 5 seconds long, was sent to him via a text, and you could see that the video was posted to the social media account of CNA 2. The admin further stated CNA 2 violated the facilities policy and procedure regarding confidentiality and HIPPA (Health Insurance Portability and Protection Act) when she recorded and posted the video of the resident on social media without his consent. During an interview on June 27, 2023, at 1:20 PM, with CNA 2, CNA 2 stated while she was working at [name of facility] in May of 2023, Resident 1 was flipping someone off while in the facility's dining room. CNA 2 stated she used her personal cell phone to record Resident 1 and posted the video on her [name of social media platform] to show what kind of day she was having at work. CNA 2 stated the story was available to be viewed for 24 hours on her webpage. CNA 2 further stated she did not receive verbal or written approval from Resident 1 to record him or post a video of him on her social media account. A review of the facility's policy and procedure (P&P) titled, Videotaping, Photographing, and other Imaging of Residents, undated, the policy indicated, Residents will be protected from invasion of privacy and/or abuse that might occur from photographs, videotapes, digital images, and recordings during resident care or other facility activities .2. Staff may not take or release images or recordings of any resident without explicit written consent. Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purposes other than investigation of abuse, neglect or emergencies .3. Transmitting unauthorized images of any resident through email, internet or social media is considered a violation of resident rights .4. Resident photographs are considered health care records and will be retained and released in accordance with current applicable regulations and statuses governing the release of protected health information . A review of the facility's P&P titled, Protected Health Information (PHI), Authorization for Use or Disclosure of, undated, the policy indicated, Policy Statement. All uses and disclosures of protected health information (PHI) beyond those otherwise permitted by current HIPAA law require a signed authorization. Policy Interpretation and Implementation. 1. The facility and its business associates have a limited right to use and/or disclose PHI health information for purposes of treatment, payment, or for the operations of the organization. 2. For other uses, there must be written authorization to release protected health information unless the law permits or requires the facility to use or disclose this information without authorization .A written or electronic copy of the authorization will be retained in the business office (or other designated location) for a period of six (6) years from the later of the date of execution or the last effective date. A review of P&P titled, Resident rights, undated, indicated, Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect, misappropriation of property, and exploitation . e. Self-determination; .g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States; h. be supported by the facility in exercising his or her rights; .t. Privacy and confidentiality; .3. the unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues. All inquiries concerning the release of resident information should be directed to the HIPAA compliance officer .4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. 5. Inquiries concerning residents' rights should be referred to the social services director.

Jul 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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to implement its policy and procedure (P&P) when a criminal background check was not conducted for a Certified Nursing Assistant (CNA 1). This failure caused CNA 1 to provide care to residents without the facility knowing if CNA 1 had a criminal history. Findings: An unannounced visit was made to the facility on July 5, 2023, at 10 AM to investigate a facility reported incident regarding an alleged staff to resident misappropriation of funds. During an interview with Resident 1 on July 5, 2023, at 11:21 AM, Resident 1 identified CNA 1 as the staff member involved in the alleged misappropriation of funds. During a concurrent interview and record review on July 5, 2023, at 1:03 PM with a Director of Staff Development (DSD), CNA 1's personnel file was reviewed. CNA 1's personnel file indicated CNA 1 had been hired on March 13, 2023. The DSD stated she did not have documented evidence to show CNA 1 had a criminal background check prior to providing care to the residents. A review of CNA 1's time sheets from May 12, 2023, to June 27, 2023, was conducted. CNA 1's time sheets indicated CNA 1 worked at the facility on the following dates: May 12, 13, 16, 17, 18, 19, 22, 23, 24, 25, 28, 29, 30, and 31, 2023 and June 3, 4, 5, 6, 9, 10, 11, 12, 15, 16, 17, 18, 21, 22, 23, 24, and 27, 2023. During an interview with the Director of Nursing (DON) on July 5, 2023, at 1:18 PM, the DON stated she did not have documented evidence to show CNA 1 had a criminal background check prior to providing care to the residents. The DON stated the facility had not followed their P&P. During a telephone interview with the Administrator (Admin) on July 6, 2023, at 5 PM, the Admin confirmed the facility could not provide documented evidence CNA 1 had a criminal background check prior to providing care to the residents. A review of the facility's P&P titled,Licensure, Certification, and Registration of Personnel, dated April 2007, indicated, .Policy Interpretation and Implementation: . 4. Our facility conducts employment background screening checks, reference checks, license verifications and criminal conviction investigation checks in accordance with current federal and state laws. 5. Personnel undergoing a background investigation, if employed, will not be permitted to perform any duties that require a license/certification/registration until such investigation reveals a current unencumbered license/certification/registration. Other duties performed during the investigation process must be performed under the direct supervision of a duly licensed/certified/registered employee. 6. Should the background investigation reveal that the employee/applicant does not hold a current unencumbered or valid license/certification/registration, the employee will not be employed (or discharged if employed) and appropriate state and federal officials will be notified of such information.

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 F0839 (Tag F0839)

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 a Certified Nursing Assistant (CNA 1) maintained a current certification in a universe of 78 residents. This failure resulted in the residents receiving nursing assistant care from an uncertified CNA 1. Findings: An unannounced visit was made to the facility on [DATE], at 10 AM to investigate a facility reported incident regarding an alleged staff to resident misappropriation of funds. During an interview with Resident 1 on [DATE], at 11:21 AM, Resident 1 identified CNA 1 as the staff member involved in the alleged misappropriation of funds. During a concurrent interview and record review on [DATE], at 1:03 PM with a Director of Staff Development (DSD), CNA 1's personnel file was reviewed. CNA 1's personnel file contained a Nurse Assistant Certification, that indicated an expiration date of [DATE]. The DSD stated she could not obtain a current certification for CNA 1. A review of CNA 1's time sheets from [DATE], to [DATE], was conducted. CNA 1's time sheets indicated CNA 1 worked at the facility on the following dates: [DATE], 16, 17, 18, 19, 22, 23, 24, 25, 28, 29, 30, and 31, 2023 and [DATE], 5, 6, 9, 10, 11, 12, 15, 16, 17, 18, 21, 22, 23, 24, and 27, 2023. During an interview with the Director of Nursing (DON) on [DATE], at 1:18 PM, the DON verified CNA 1's certification had expired, and the facility could not show documented evidence of a current certification for CNA 1. The DON confirmed CNA 1 had provided care to residents with an expired certification. The DON stated the facility had not followed their policy and procedure (P&P) titled, Licensure, Certification, and Registration of Personnel, dated [DATE]. A review of the facility's P&P titled, Licensure, Certification, and Registration of Personnel, dated [DATE], indicated, .Policy Interpretation and Implementation: .2. A copy of the current license, certification, or registration number must be filed in the employee's personnel record. 3. A copy of recertifications (e.g., annual, bi-annual, etc., as applicable) must be presented to the Human Resources Director/designee upon receipt of such recertifications and prior to the expiration of current licensure, certification, and/or registration. A copy of the recertification must be filed in the employee's personnel record .

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a fall mat (a cushioned mat which may aid in lessening the severity of injury during a fall) next to his bed as was specified in the Resident 1's care plan (an individualized plan for the medical care of a resident). This failure had the potential for Resident 1's to sustain an injury during a fall. Findings: During a review of Resident 1's admission Record (clinical record with demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included dementia (a brain disease that causes memory disorders, personality changes, and impaired reasoning), Delirium (a mental state in which you are confused, disoriented, and not able to think or remember clearly), and schizoaffective disorder (a mental health condition characterized primarily by delusions, hallucinations, and mood disorder). During a review of Resident 1's Fall Risk Assessment (an assessment which identifies how much a resident is at risk for falls), dated April 14, 2023, the assessment indicated Resident 1 was high risk for falls. Further review of the assessment indicated Resident 1 had a history of 3 or more falls within the prior 3 months, had balance problems while standing and walking and had decreased muscular coordination. During a review of Resident 1's physician's orders, an order dated April 13, 2023, indicated, Low bed with floor mat to decrease potential injury . During a review of Resident 1's care plan titled, Floor Mat, dated April 13, 2023, the care plan indicated, [name of Resident 1] is at high risk for falls with interventions that include low bed and floor mat .Interventions - Continue with low bed with floor mat . During a review of Resident 1's Interdisciplinary Team [IDT - a team of individuals with various backgrounds or specialties] Post Fall Review (a resident assessment performed after a fall), dated April 16, 2023, the assessment indicated, Root Cause Analysis .resident tripped over floor mat .Resident was sent out for further evaluation and returned with dx [diagnosis] of mildly depressed fracture of the nasal spine. Interventions: Beveled floor mat [a low profile floor mat] with non skid tape . During an observation on May 31, 2023, in Resident 1's room, Resident 1 was lying in bed and did not have a fall matt next to his bed. During an interview on May 31, 2023, at 2:43 PM, with the Director of Nursing (DON), the DON stated she was involved in the investigation of Resident 1's fall which occurred on April 14, 2023. The DON stated Resident 1 was supposed to have a floor matt next to his bed and that as a result of the investigation, the IDT recommended a beveled floor matt to be used instead of the tri-fold floor matt. During a concurrent observation and interview on May 31, 2023, at 2:48 PM, with the DON, in Resident 1's room, Resident 1 was lying in his bed and did not have a floor matt on either side of the bed. The DON stated Resident 1 was supposed to have a floor mat, but he did not. The DON further stated it was the responsibility of all staff to ensure the floor matt was in place whenever they entered the room. The DON stated she did not know why Resident 1's floor matt was not present and that the importance and purpose of the floor matt was to lessen a potential injury in case Resident 1 had a fall. During a review of the facility's policy and procedure (P&P) titled, Falls - Clinical Protocol, undated, the policy indicated, . the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of clinically significant consequences of falling .Monitoring and follow-up .2.b. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented. During a review of the facility's P&P titled, Falls and Fall risk, Managing, revised March 2018, the policy indicated, .Staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling .7. In conjunction with the attending physician, staff will identify and implement relevant interventions .to try to minimize serious consequences of falling . During a review of the facility's P&P titled, Safety and Supervision of Residents, undated, the policy indicated, Our facility strives to make the environment as free from accident hazards as possible .2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following .a. communicating specific interventions to all relevant staff; b. assigning responsibility for carrying out interventions; .d. Ensuring that interventions are implemented .

Feb 2023 9 deficiencies

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a Minimum Data Set (MDS) (a computerized clinical assessment) Significant Change Assessment (SCA) within 14 days for two of three sampled residents (Residents 31 and 27) who were reviewed for hospice (a program providing services for the care of terminally ill residents and their family) services as evidenced by: 1. The facility did not complete a MDS SCA for Resident 31 within 14 days of admission to hospice services. 2. The facility did not complete a MDS SCA for Resident 27 within 14 days of admission to hospice services. This failure had the potential to delay identification and implementation of necessary interventions to address the resident's care and support needs. Findings: 1. During a review of Resident 31's medical record, the admission Record (clinical records with demographic information) indicated the resident was admitted to the facility on [DATE]. The record further indicated the resident was admitted to hospice services on July 16, 2022, with diagnoses which included senile degeneration of the brain (mental deterioration or loss of intellectual ability associated with old age), encounter for palliative care (treatment given to relieve pain and control symptoms when there is no expectation of a cure), and dementia ( a condition characterized by progressive loss of intellectual functioning, impairment of memory and personality change). During a review of Resident 31's MDS record, on February 22, 2023, at 8:50 AM, the record indicated MDS SCA was completed on October 14, 2022. During an interview with the MDS Nurse (MDS 1) on February 22, 2023, at 10:50 AM, MDS 1 verified the MDS SCA was completed on October 14, 2022. MDS 1 stated a SCA should have been completed within 14 days of when the resident was admitted to hospice services. During a review of the facility's MDS Completion and Submission Timeframes policy, revised July 2017, the policy indicated .2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. During a review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2019, the manual indicated on page 2-23, An SCSA [significant change in status assessment] is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election . An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. 2. During a review of Resident 27's admission Record, the record indicated Resident 27 was admitted to the facility on [DATE], and was admitted to hospice services on August 19, 2022. The record further indicated Resident 27 had diagnoses which included senile degeneration of the brain (the mental loss of intellectual ability that is associated with old age), mild protein calorie malnutrition, and unspecified dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and personality change). During a review of Resident 27's MDS record, the record indicated there had not been a MDS SCA completed for Resident 27 within 14 days of their admission to hospice services. During a concurrent interview and record review on February 23, 2023, at 11:15 AM, with the MDS Nurse (MDS 2), Resident 27's MDS Significant Change Assessment, dated October 19, 2022 was reviewed. MDS 2 confirmed the target date of completion for Resident 27's MDS SCA was August 26, 2022, but the date of completion was October 19, 2022. MDS 2 stated Resident 27's significant change assessment was completed almost two months after the specified target date. MDS 2 further stated, MDS significant change assessments for residents were to be completed within 14 days, per facility policy. During a review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2019, the manual indicated, .An SCSA [significant change in status assessment] is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [assessment reference date] must be within 14 days from the effective date of the hospice election . An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place .

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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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately reflect the resident's status in the Minimum Data Set (MDS - Computerized resident assessment completed by a licensed nurse) Assessments when Section H: Bowel and Bladder was inaccurately coded for one sampled resident (Resident 59). This failure to correctly notify the oversight agency (Centers for Medicare and Medicaid Services - CMS) who provides funding for residents, has the potential for monies to continue to be paid to the facility for services not rendered to the resident. Findings: During a review of Resident 59's clinical record, the admission Record (contains admission and demographic information) indicated the resident was admitted on [DATE], with diagnoses which included infection of the skin, neuromuscular dysfunction of the bladder (lack of bladder control due to nerve problems), and paraplegia (paralysis of lower limbs). During a concurrent observation and interview on February 23, 2023, at 3:12 PM, Resident 59 was observed in bed, with a urinary catheter (a tube inserted into the bladder to allow urine drainage) bag hanging on the bedside. When asked about his catheter, Resident 59 stated he had a suprapubic catheter (urinary catheter inserted into the bladder externally, through the pelvic area) in place, and denied he had any other form of an ostomy (surgical opening) on his body. During a concurrent interview and record review with a MDS Nurse (MDS 1), on February 24, 2023, at 9:10 AM, Resident 59's MDS admission Assessment, dated January 10, 2023, was reviewed. The MDS assessment indicated under Section H: Bowel and Bladder, both options for coding indwelling catheter and ostomy had been selected. MDS 1 verified the assessment had been coded incorrectly and should have only had indwelling catheter selected. During a review of CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, dated October 2019, the manual indicated on page H-2 Suprapubic catheters and nephrostomy tubes should be coded as an indwelling catheter (H0100A) only and not as an ostomy (H0100C).

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 properly assess and address pain levels, by not following physician's orders for pain medication, for one sampled resident (Resident 4). This failure had the potential to cause the resident to experience avoidable discomfort and pain. Findings: During a review of Resident 4's clinical record, the admission Record (contains admission and demographic information) indicated the resident was admitted on [DATE], with diagnoses which included cerebral infarction (lack of blood supply to the brain), heart failure (long term weakness of the heart muscle), and dementia (impaired ability to remember, think, or make decisions). Further review of the clinical record indicated there was a current physician's order for Norco (narcotic pain medication) Oral Tablet 10-325 mg (mg-milligrams - unit of measurement) Give 1 tablet by mouth every 6 hours as needed for Pain Management Moderate-Severe Pain 7-10 (pain rated on a scale from one [no pain] through 10 [severe pain]). During a concurrent observation and interview on February 21, 2023, at 9:22 AM, Resident 4 was observed lying in bed, humming and mumbling words to herself. When asked if she was experiencing any pain, Resident 4 stated she experienced pain often. Resident 4 further stated her pain was located all over her body, and not just one localized place. During an interview with a licensed vocational nurse (LVN 1) on February 24, 2023, at 8:15 AM, LVN 1 stated that Resident 4 often stated her pain scale was above seven. LVN 1 further stated even if the pain scale was below five, Resident 4 usually requested for the Norco medication because she says it's the only thing that works for her. During a concurrent interview and record review with the Director of Nursing (DON), on February 24, 2023, at 9:15 AM, Resident 4's Medication Administration Record (MAR) was reviewed. The MAR indicated Resident 4 had requested her Norco medication every day for the past 23 days of February. The MAR further indicated that the Norco medication had been given seven times for a pain scale less than 7. The DON stated this was not following physician's orders. The DON further stated if the resident was asking for the medication consistently, then the resident's pain was not being managed. The DON stated her expectations were for the nurses to contact the Physician, notify them, and inquire about adjusting the pain medication orders to ensure resident's needs are met. During a review of the facility's policy and procedure (P&P), titled Administering Medication, revised April 2019, the P&P indicated .4. Medications are administered in accordance with prescriber orders, including any required time frame . During a review of the facility's policy and procedure (P&P), titled Pain Evaluation and Management, revised March 2020, the P&P indicated .5. Review the medication administration record to determine how often the individual requests and receives PRN pain medication .

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for two (2) of six (6) residents (Resident 48 and Resident 62) observed during medication passes as follows: 1. For Resident 48 the manufacturer's specifications were not followed when Pantoprazole Sodium Delayed Release was crushed. 2. For resident 62 the physician's order for the Cranberry Supplement was not followed. This resulted in a medication error rate of 6.06 % in the 33 opportunities observed and had the potential to reduce the efficacy of the medications and to cause stomach irritation for Residents 48 and gave the wrong dose for Resident 62. Findings: 1. During a review of Resident 48's medical record, the admission Record (contains medical and demographic information), indicated Resident 48 was admitted on [DATE], with diagnoses which included unspecified encephalopathy (brain disease that alters brain function or structure), cerebral infarction (disrupted blood flow to the brain due to unspecified occlusion of right middle cerebral artery) and gastro esophageal reflux disease (GERD-acid reflux) without esophagitis (inflammation of the esophagus- muscular tube through which food passes from the throat to the stomach). During a concurrent observation and interview on February 23, 2023, at 7:00 AM, with a Licensed Vocational Nurse (LVN 3) outside Resident 48's room, LVN 3 was observed crushing a yellow pill which she identified as Pantoprazole tablet (a medication used to treat gastroesophageal reflux disease (GERD) (occurs when stomach acid repeatedly flows back into the esophagus (tube connecting your mouth and stomach) and a damaged esophagus). LVN 3 stated, Resident 48 preferred her medication crushed. During a concurrent interview and record review, on February 23, 2023, at 7:05 AM, with LVN 3 Resident 48's physician's order for Pantoprazole dated April 24, 2022, was reviewed. The physician's order indicated, Pantoprazole Sodium Tablet Delayed Release 40 mg (milligram-a unit of measurement). Give 1 tablet by mouth in the morning for GERD. LVN 3 could not show where the physician had ordered for the medication to be crushed and stated she was not aware that Pantoprazole could not be crushed. During a telephone interview with the Consultant Pharmacist on February 23, 2023, at 11:52 AM, the Consultant Pharmacist stated to maximize the full effect of the drug Pantoprazole Delayed Release, it should not be crushed. He also stated the pharmacy who dispensed the drug should have labeled the medication package with instructions for not crushing the medication. The Consultant Pharmacist further stated nurses should know, Pantoprazole delayed release should not be crushed because it is a standard of practice. During a review of the manufacturer's administration instruction, dated April 2022, indicated, Pantoprazole Sodium - pantoprazole tablet, delayed release, [Name of manufacturer] . Table 2: Administration instructions: Formulation: Delayed Release Tablets, Route: Oral, Instructions* Swallow whole, with or without food.* Do not split, chew, crush pantoprazole sodium delayed- release tablets. During a concurrent interview and record review on February 23, 2023, at 12:01 PM, with the Director of Nursing (DON), Resident 48's physician's order for Pantoprazole dated April 24, 2022, was reviewed. The DON verified physician's order indicated, Pantoprazole Sodium Delayed Release 40mg. Give 1 tablet by mouth in the Morning. Also reviewed with the DON was the manufacturer's administration instructions for Pantoprazole sodium delayed release which indicated not to chew or crush. The DON stated LVN 3 crushed the medication and did not follow manufacturer administration instruction. During a review of the facility's policy and procedure titled, Crushing Medications, undated, indicated, The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush drugs that the manufacturer stated should not be crushed (for example, long acting or enteric (relating to or occurring in the intestines) coated medications. 2. During a review of Resident 62's medical record, the admission Record, indicated Resident 62 was admitted on [DATE], with diagnosis which included encephalopathy, chronic kidney disease and urinary tract infection (an infection in the kidneys or bladder). During an observation on February 23, 2023, at 9:19 AM, with LVN 1 outside Resident 62's room, LVN 1 was observed taking a medication from a house supply bottle labeled, Cranberry: Cranberry Supplement .60 Capsules- 425 mg each. LVN 1 took one tablet and placed it in a medicine cup, crushed the medication, added apples sauce, and gave it to Resident 62. During a review of Resident 62's physician's order dated January 4, 2023, indicated, Cranberry tablet 300mg. Give 1 tablet by mouth one time a day for supplement. During a medication reconciliation on February 23, 2023, at 10:45 AM, with the DON and LVN 1, Resident 62's physician's order dated January 4, 2023, was reviewed. It indicated Cranberry tablet 300mg. Give 1 tablet by mouth one time a day for supplement. LVN 1 and the DON compared the order with the house supply bottle labeled, Cranberry: Cranberry Supplement .60 Capsules- 425 mg each. LVN 1 stated she did not follow physician's order when she gave the Cranberry supplement tablet that is 425 mg instead of the 300mg as ordered. DON agreed with LVN 1, stating, She didn't follow MD orders for the Cranberry tablets. During a review of the facility's policy and procedure titled, Administering Medications undated, indicated, .4. Medications are administered in accordance with prescriber order .10. The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage .

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow manufacturer's specifications for Pantoprazole Sodium Delayed Release tablet ordered for Resident 48. This failure had the potential for Resident 48 not to receive the maximum effect of the medication. Findings: During a review of Resident 48's medical record, the admission Record (contains medical and demographic information), indicated Resident 48 was admitted on [DATE], with diagnoses which included unspecified encephalopathy (brain disease that alters brain function or structure), cerebral infarction (disrupted blood flow to the brain due to unspecified occlusion of right middle cerebral artery) and gastro esophageal reflux disease (GERD-acid reflux) without esophagitis (inflammation of the esophagus- muscular tube through which food passes from the throat to the stomach). During a concurrent observation and interview on February 23, 2023, at 7:00 AM, with Licensed Vocational Nurse (LVN 3) outside Resident 48's room, LVN 3 was observed crushing a yellow pill which she identified as Pantoprazole tablet (treat gastroesophageal reflux disease (GERD) (occurs when stomach acid repeatedly flows back into the esophagus (tube connecting your mouth and stomach). LVN 3 stated, Resident 48 preferred her medication crushed. During a concurrent interview and record review, on February 23, 2023, at 7:05 AM, with LVN 3 Resident 48's physician's order for Pantoprazole dated April 24, 2022, was reviewed. The physician's order indicated, Pantoprazole Sodium Tablet Delayed Release 40 mg (milligram- unit of measurement). Give 1 tablet by mouth in the morning for GERD. LVN 3 could not show where the physician had ordered for the medication to be crushed and stated she was not aware that Pantoprazole could not be crushed. During a telephone interview with the Consultant Pharmacist on February 23, 2023, at 11:52 AM, the Consultant Pharmacist stated to maximize the full effect of the drug Pantoprazole Delayed Released, it should not be crushed. He also stated the pharmacy who dispensed the drug should have labeled the medication package with instructions for not crushing the medication. The Consultant Pharmacist further stated nurses should know, Pantoprazole delayed release should not be crushed because it is a standard of practice. During a review of manufacturer's administration instruction, dated April 2022, indicated, Pantoprazole Sodium - pantoprazole tablet, delayed release, {Name of manufacturer} . Table 2: Administration instructions: Formulation: Delayed Release Tablets, Route: Oral, Instructions* Swallow whole, with or without food.* Do not split, chew, crush pantoprazole sodium delayed- release tablets. During a concurrent interview and record review on February 23, 2023, at 12:01 PM, with the Director of Nursing (DON), Resident 48's physician's order for Pantoprazole dated April 24, 2022, was reviewed. The DON verified physician's order indicated, Pantoprazole Sodium Delayed release 40mg. Give 1 tablet by mouth in the Morning. Also reviewed with the DON was the manufacturer's administration specifications for Pantoprazole sodium delayed release which indicated not to chew or crush. The DON stated LVN 3 crushed the medication and did not follow manufacturer administration instructions. During a review of the facility's policy and procedure titled, Crushing Medications, undated, indicated, The nursing staff and/or consultant pharmacist shall notify any attending physician who gives an order to crush drugs that the manufacturer stated should not be crushed (for example, long acting or enteric (relating to or occurring in the intestines) coated medications.

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** Based on observation, interview, and record review, the facility failed to ensure food prepared for residents on a Pureed Diet (texture modified diet where all foods are blended to a mashed potato consistency) was palatable for lunch on February 22, 2023, when five out of five residents (Resident 4, 56, 28, 27, and 25) on a Pureed Diet were served pureed meatloaf that was not palatable and did not taste comparable to the meatloaf that was served to the residents receiving a Regular Diet (diet with no restrictions). This failure had the potential to cause the residents on a Pureed Diet to experience a decrease in food intake which could lead to poor nutrition and health outcomes for these vulnerable residents in the facility. Findings: During a concurrent interview and meal taste test of the lunch that was served on February 22, 2023, at 1:06 PM, at Nursing Station 1, with Registered Dietitian 2 (RD 2), sample trays of the Regular Diet and Pureed Diet were tested for palatability, appearance, texture, and temperature. The sample trays consisted of meatloaf, peas with peppers, and scalloped potatoes. The pureed meatloaf was a light brown color, while the regular meatloaf was dark brown with gravy. The regular meatloaf tasted flavorful, but the pureed meatloaf tasted bland and not comparable to the regular meatloaf served. The RD 2 stated that the meatloaf tasted like potato flakes and did not taste like meatloaf at all. During an interview on February 23, 2023, at 11:57 AM, with Registered Dietitian 1 (RD 1), RD 1 stated the pureed diet meals should taste like the regular diet meals for the residents. During an interview on February 22, 2023, at 3:06 PM, in the Secured Memory Care Unit's (locked unit for residents with memory impairment) facility dining room with Resident 27, Resident 27 was not able to verbalize their level of satisfaction for the lunch meal. During a review of Resident 27's medical record, the admission Record, (contains admission and demographic information) dated February 22, 2023, the admission Record showed Resident 27 was admitted to the Memory Care Unit on September 20, 2019, with a primary diagnosis (main disease affecting a person) of unspecified dementia (impaired ability to remember, think, or make decisions). During a review of the facility document titled, Diet Type Report, dated February 22, 2023, the document indicated Resident 27 was on a Fortified Diet (diet with added nutrients) with pureed texture. During a concurrent observation and interview on February 23, 2023, at 8:02 AM, with Resident 56 and Certified Nurse Assistant (CNA 1), in Resident 56's bedroom, CNA 1 was feeding breakfast to Resident 56. Resident 56 was lying in bed and was unable to verbalize her satisfaction with her breakfast. CNA 1 stated Resident 56 does not usually talk or respond. During a review of Resident 56's medical record, the admission Record, dated February 22, 2023, the admission Record indicated Resident 56 was admitted on [DATE], with a primary diagnosis of hemiplegia (paralysis to one side of the body) following cerebrovascular disease (disease that affect blood flow and blood vessels in the brain). During a review of the facility document titled, Diet Type Report, dated February 22, 2023, the document indicated Resident 56 was on a Fortified CCHO (consistent carbohydrate - diet indicated for people with diabetes mellitus, a disease that alters how the body processes sugar) Diet with pureed texture and required feeding assistance with all meals. During a review of the facility document titled, Diet Type Report, dated February 22, 2023, the document indicated five of the 77 residents were on a pureed diet in the facility. During a review of the facility's policy and procedure (P&P), titled, Meal Service, dated 2018, the P&P indicated Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner . During a review of the facility's P&P titled, Menu Planning, dated 2020, the P&P indicated, .4. The menus are planned to meet the nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and National Board of the National Research Council National Academy of Sciences.

CONCERN (E)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to prepare food in a form that met individual needs when 28 of 28 residents on a Mechanical Soft Diet (altered-texture diet for people who have difficulty chewing and swallowing) were served toasted bread with crust when the menu indicated they should have received soft bread with no hard crusts. This failure had the potential for the affected residents to choke and/or aspirate (accidental breathing of food or fluid into lungs) with the restricted food forms, which could have resulted in resident harm. Findings: During an observation on February 21, 2023, at 12:05 PM, in the facility kitchen during the plating of the residents' lunches, [NAME] 1 served the residents on a Mechanical Soft Diet toasted garlic bread with crust. During a review of the facility document titled, Cooks Spreadsheet, dated February 21, 2023, the document indicated for lunch on February 21, 2023, residents on a Mechanical Soft Diet should have received Soft-No hard crusts for the bread option. During a concurrent observation and interview on February 21, 2023, at 12:33 PM, with the Dietary Services Supervisor (DSS), the DSS tasted the toast that was served to residents on the Mechanical Soft Diet and stated the crust on the toast should have been cut off. During a review of the facility document titled, Regular - Mechanical Soft Diet, dated 2020, the document indicated the acceptable grains for a Mechanical Soft Diet were soft breads, and the grains to be avoided were breads with hard crusts. During an interview on February 23, 2023, at 11:57 AM, with Registered Dietician 1 (RD 1), RD 1 stated the safest thing to do was to serve bread with no crust or choose a bread that was soft.

CONCERN (F)

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

Menu Adequacy (Tag F0803)

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 the lunch menu was being followed on February 21, 2023, when: 1. Six residents on a Pureed Diet (texture modified diet where all foods are blended to a mashed potato consistency) received a half-cup serving of Chicken Jambalaya (meat and rice dish), when the menu indicated a one-cup serving of Chicken Jambalaya should have been provided. 2. 62 Residents on a Regular Diet (diet that does not include any meal restrictions), Mechanical Soft Diet (altered-texture diet for people who have difficulty chewing and swallowing), and a CCHO Diet (consistent carbohydrate - diet indicated for people with diabetes mellitus, a disease that alters how the body processes sugar) received the wrong meal portion of Chicken Jambalaya. The residents on these diets received a two-thirds cup of Chicken Jambalaya, when the menu indicated a one-cup serving of Chicken Jambalaya should have been provided. 3. One resident on a Finger Food Diet (diet to be eaten using fingers) received a bowl of rice, when they should have received a serving of pasta. These failures had the potential for residents to receive inadequate caloric intake when the established menu was not being followed accordingly, which could have resulted in poor nutrition and further compromise the medical status of the 69 residents. Findings: 1. During observation on February 21, 2023, at 12:05 PM, in the kitchen, while the cook was portioning out food for each residents' plate, [NAME] 1 served the Pureed Diet meals using one #8 (half-cup) scoop of Chicken Jambalaya. During a review of the facility document titled, Cooks Spreadsheet, dated February 21, 2023, the document indicated, the Pureed Diet meal should get a one-cup serving of Chicken Jambalaya. During an interview on February 21, 2023, at 3:08 PM, in the facility kitchen, with [NAME] 1, [NAME] 1 stated she thought that the serving size for the #8 scoop was one-cup. During a concurrent interview and record review on February 22, 2023, at 3:12 PM, with the Dietary Services Supervisor (DSS), the DSS reviewed the facility document titled, Portion Control Chart, and verified that the serving size for a #8 scoop was a half-cup. The DSS confirmed that residents on a Pureed Diet received only a half-cup serving of Chicken Jambalaya, when they should have received a one-cup serving. The DSS stated, the cook should have been using the correct scoop size. The DSS further stated, according to the menu and for a one-cup serving, the cook would have needed to use two #8 scoops, because they did not have a one-cup scoop. During an interview on February 23, 2023, at 11:57 AM, with Registered Dietitian 1 (RD 1), RD 1 stated, it was the expectation that the cook should follow the menu and serve the portions listed on the facility document, Cooks Spreadsheet. During a review of the facility document titled, Diet Type Report, dated February 22, 2023, the document indicated five residents of the 77 residents in the facility were on a Pureed Diet. During a review of the facility's policy and procedure (P&P), titled, Meal Service, dated 2018, the P&P indicated Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner . During a review of the facility's P&P titled, Menu Planning, dated 2020, the P&P indicated, .4. The menus are planned to meet the nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and National Board of the National Research Council National Academy of Sciences. 2. During an observation on February 21, 2023, at 12:05 PM, in the facility kitchen, [NAME] 1 served the Mechanical Soft Diets, the Regular Diets, and the CCHO Diets using a #6 (two-thirds cup) scoop of Chicken Jambalaya. Record review of the facility document titled, Cooks Spreadsheet, dated February 21, 2023, indicated that the Mechanical Soft Diets, the Regular Diets, and the CCHO Diets, should be served one cup of Chicken Jambalaya. During a concurrent interview and record review on February 21, 2023, at 3:12 PM, with the DSS and [NAME] 1, the DSS and [NAME] 1 reviewed the facility document titled, Portion Control Chart, and verified that the serving size for a #6 scoop was a two-thirds cup. The DSS confirmed that residents on the Mechanical Soft Diet, the Regular Diet, and the CCHO Diets should have received a one-cup serving of Chicken Jambalaya. During an interview on February 23, 2023, at 11:57 AM, with RD 1, RD 1 stated, it was expected that the cook followed the menu and serve the portions that are indicated on the facility document, Cooks Spreadsheet. During a review of the facility document titled, Diet Type Report, dated February 22, 2023, the document indicated, 62 out of 77 residents were on Mechanical Soft, Regular, or CCHO Diets. During a review of the facility's policy and procedure (P&P), titled, Meal Service, dated 2018, the P&P indicated Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner . During a review of the facility's P&P titled, Menu Planning, dated 2020, the P&P indicated, .4. The menus are planned to meet the nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and National Board of the National Research Council National Academy of Sciences. 3. During a concurrent observation and record review on February 21, 2023, at 12:30 PM, Resident 74 was eating lunch in the facility dining room. Resident 74's tray ticket indicated she was on a Finger Food Diet. Resident 74's lunch tray was observed to contain toast, a bowl of rice, a bowl of chicken, and a bowl of zucchini. During an interview on February 21, 2023, at 3:25 PM, [NAME] 1 stated, Resident 74 should have been served pasta instead of rice for the Finger Food Diet. During an interview on February 23, 2023, at 11:57 AM, with RD 1, RD 1 stated, Resident 74 should have been served pasta, and if they did not have pasta in stock, the cook could have wrapped the rice in a tortilla, to make it easier for the resident to eat. During a review of the facility document titled, Diet Type Report, dated February 22, 2023, the document indicated, Resident 74 was on a Fortified (added nutrients), Mechanical Soft Diet, and does best with FINGER FOODS, such as finger foods. During a review of the facility document titled, Regular Diet - Finger Foods, dated 2020, the document indicated, examples of grains for a Finger Food Diet may include: biscuits, bread, chips, crackers, french fries, large pasta, muffins, pancake, rolls, or tortilla. The document further indicated, Choose thick, large pasta such as tortellini, penne, rotini, or bowties that are easy to pick up. During a review of the facility's policy and procedure (P&P), titled, Meal Service, dated 2018, the P&P indicated Meals that meet the nutritional needs of the resident will be served in an accurate and efficient manner . During a review of the facility's P&P titled, Menu Planning, dated 2020, the P&P indicated, .4. The menus are planned to meet the nutritional needs of residents in accordance with established national guidelines, Physician's orders and, to the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and National Board of the National Research Council National Academy of Sciences.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 46 resident rooms (rooms [ROOM NUMBERS]) had the required 80 square feet (Sq Ft - unit of measurement) of space for each resident. This failure had the potential to limit freedom of movement and affect the health and safety of four residents (Residents 71, 68, 57, and 229) who reside in the two rooms. Findings: During concurrent observation and interviews with the residents in room [ROOM NUMBER], on February 21, 2023, at 9:30 AM the following were observed: a. Bed A was occupied by Resident 71, who was observed resting comfortably in bed. Resident 71 stated she occasionally gets up into the wheelchair with staff assistance. Her wheelchair was folded up and stored in the room, out of the way of foot traffic, but easily accessible. b. Bed B was occupied by Resident 68, who was observed sitting in bed. Resident 68 stated she occasionally gets up into the wheelchair with staff assistance. Her wheelchair was folded up and stored near the foot of her bed, along the wall of the room. During concurrent observation and interviews with the residents in room [ROOM NUMBER], on February 21, 2023, at 10:08 AM, the following were observed: c. Bed A was occupied by Resident 57, who was observed sitting on the edge of his bed. His wheelchair and a commode were located at his bedside. Resident 57 denied feeling any restrictions of movement and stated he was able to transfer to his chair and use his commode without difficulty. d. Bed B was occupied by Resident 229, who was observed resting in bed. Resident 229's wheelchair was folded in half and stored in the room, out of the way of foot traffic, but easily accessible. During an environmental tour of rooms [ROOM NUMBERS], with the Maintenance Supervisor (MS) and Maintenance Assistant (MA), on February 24, 2023, at 9:33 AM, the following measurements were noted as follows: 1. room [ROOM NUMBER] measured 11.4 feet (ft) x 12.9 ft = 147 sq ft total (73.5 sq ft per resident) 2. room [ROOM NUMBER] measured 11.4 ft x 12.7 ft = 144.8 sq ft total (72.4 sq ft per resident) During an interview with the Administrator (ADMIN) on February 24, 2023, at 10:00 AM, the ADMIN stated he was aware of the rooms not meeting requirements for sq ft per resident. The ADMIN further stated they apply for the room waiver annually, with last waiver application submitted on July 14, 2022. During a review of the facility's policy and procedure (P&P), Bedrooms, undated, the P&P indicated .2. Bedrooms measure at least 80 square feet of space per resident double rooms . During the course of the survey, rooms [ROOM NUMBERS] were not crowded and did not impose any safety hazards. There were no complaints of space or room issues from the residents occupying these rooms.

Feb 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 F0921)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public when the facility's dining room ceiling was leaking. This failure has the potential to result in jeopardizing the health and safety of the public, staff, and clinically compromised residents. Finding: An unannounced visit was made to the facility on January 17, 2023, at 12 PM, to investigate a complaint about facility's dining room leaking. During an observation of the facility's dining room on January 17, 2023, at 12:28 PM, the dining room ceiling was leaking. There were 7 buckets catching water dripping from the dining room ceiling, patches of plaster peeling off, and water stains throughout the dining room ceiling. During an interview with Facility Maintenance Director (FMD) on January 17, 2023, at 12:32 PM, FMD confirmed the facility's dining room ceiling was leaking. The FMD stated, I am going to fix it. We had a big rainstorm yesterday. During an interview with the administrator (ADM) on January 17, 2023, at 12:45 PM, the ADM confirmed the facility's dining room ceiling was leaking. ADM stated, We have received several roof estimates. The roof will be fixed soon. During a review of the facility's policy and procedure titled, Maintenance Service, revised December 2009, indicated, maintenance service shall be provided to all areas of the building, grounds, and equipment. Further review of the facility's policy and procedure titled, Maintenance Service, indicated, Maintaining the building in good repair and free from hazards. During a review of the facility's policy and procedure titled, Homelike Environment, undated, indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

Jan 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement an intervention listed in the fall prevention care plan for one of three sampled residents (Resident 1) when non-skid, proper fitting socks/shoes were not provided. This failure had the potential for Resident 1 to have a fall. Findings: An unannounced visit was made to the facility on November 28, 2022, at 4:10 PM to investigate a complaint about a fall on October 28, 2022, for Resident 1. During an observation of Resident 1 on November 28, 2022, at 4:20 PM, resident 1 was up in a wheelchair in the dining room. Resident 1 did not have non-skid, proper fitting socks/shoes. During an interview with Resident 1 on November 28, 2022, at 4:30 PM, Resident 1 stated, I slipped and I fell to the floor last month. During an interview with CNA 1 on November 28, 2022, at 4:45 PM, CNA 1 confirmed Resident did not have non-skid proper fitting socks/shoes. CNA 1 stated, The resident should be wearing anti-skid socks to prevent him from falling. During a review of Resident 1's Fall risk assessment dated [DATE], Resident 1 was a high risk for falls. During a review of Resident 1's care plan for falls with an implementation date of October 28, 2022, one of the interventions listed was for Resident 1 to wear non-skid, proper fitting socks/shoes. During a review of a policy and procedure titled, Falls-Clinical Protocol for [name of corporation], undated, indicated, The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. During a review of Resident 1's face sheet (a document which contains basic information about the resident), documented Resident 1 was admitted to the facility on [DATE], with diagnoses which included abnormalities of gait (walking) and mobility, osteoporosis (brittle bones), muscle weakness, repeated falls

Jul 2021 12 deficiencies 2 IJ (2 facility-wide)

CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0801 (Tag F0801)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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Based on observation, interview, and record review, the facility failed to employ a full-time (35 hours per week) qualified dietitian or designate a person to serve as director of food and nutrition services when their Dietary Services Supervisor quit on June 11, 2021. This resulted in the food services department lacking in oversight which led to unsanitary conditions in the kitchen when the following were found: A. Shelf was deteriorating from water damage. B. The floors under all shelving and equipment and in the dry storage were dirty with food debris and trash. C. The two stoves had a black grime, and the floor underneath the stoves had a build-up of black grime and rotting food. D. Dead rodents and roaches were found. E. The enclosed area under the food prep sink was dirty with a brown grime. F. The patched wall behind the three-compartment sink (three separate sink compartments, one for each step of the dishwashing procedure: wash, rinse, and sanitize) was not smooth which made the surface not easily cleanable. These failures resulted from lack of qualified oversight to do daily inspections, provide feedback to staff, ensure staff is doing their job which had the potential to cause foodborne illness to 73 of 73 residents who were medically compromised. Findings: During an interview on June 29, 2021, at 7:25 AM, the Dietary Services Supervisor (DSS 1), stated that she works at their sister facility and comes to the facility a two times per week to help. The previous Dietary Services Supervisor (DSS 2) quit a few weeks prior. During a tour of the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021 between 7:25 AM and 8:26 AM, the following were observed: a. The shelf that was holding the coffee maker and the juice machine had water damage and the edges were deteriorating. The DSS 1 stated that they plan to get that cabinet replaced. b. The floor under the ice machine and where the food carts were stored was with food particles and dirt. The floor under the three-compartment sink was dirty with debris and trash. The floor under the metal rack that contained clean pots and pans had food debris and dirt. The baseboard had a sticky yellow residue. The floor under the convection oven was dirty with a greasy residue. The DSS 1 stated that the floors should be kept clean. c. The knobs on the stove that lights the burners were covered in a black grime and the front of the stove around the knobs was covered in black grime. The floors under the two stoves had a black grime. Under the stove to the right, there was a whole tomato rotting and the floor was covered in a black grime. d. A glue trap was found in the oven with four dead mice. The DSS 1 stated that she did not know that the mice were there. A sticky trap was observed under the shelf in the dry storage room with five dead roaches. The DSS 1 stated that staff should have discarded the trap. During a follow up observation and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 30, 2021 at 8:46 AM, the following were observed: e. The enclosed area under the food prep sink was dirty with a thick layer of brown grime. This area is adjacent and open to the 3 drawers containing clean utensils for serving food. f. The wall behind the 3-compartment sink appeared to have been repaired. Some spackle was used to cover the edges, but the drywall was visible, and the wall was not smooth. It had lumps of spackle. During an interview on June 29, 2021, at 9:28 AM, the Registered Dietitian (RD 2) stated that she has been there two months. She was covering for the RD 1 because she is on maternity leave. RD 2 stated she was not full-time, but she comes every Wednesday. The RD 2 verified that they currently do not have a full-time Dietary Services Supervisor. During an interview on July 1, 2021, at 10:00 AM, the Administrator stated that they were splitting the time with the Registered Dietitian 2 and the DSS 1 from the sister facility and he was not aware it had to be one person full time to manage the Food and Nutrition Services. According to the Health and Safety Code 1265.4, (a) A licensed health facility, as defined in subdivision (a), (b), (c), (d), (f), or (k) of Section 1250, shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations. The dietetic services supervisor shall receive frequently scheduled consultation from a qualified dietitian. According to Title 22 72351 (a) A dietitian shall be employed on a full-time, part-time or consulting basis. Part-time or consultant services shall be provided on the premises at appropriate times on a regularly scheduled basis. A written record of the frequency, nature and duration of the consultant's visits shall be maintained. (b) If a dietitian is not employed full-time, a full-time dietetic services supervisor shall be employed to be responsible for the operation of the food service. The dietetic supervisor may also cook, provided sufficient time is allowed for managerial responsibilities. During a review of an email resignation from the former Dietary Services Supervisor (DSS 2), dated June 7, 2021, the resignation indicated This letter is to inform you that I am resigning from my current position of Dietary Service Supervisor at [Facility Name], effective June 11, 2021. During a review of the FDA Federal Food Code 2017, indicates Except as specified in (B) of this section, the permit holder (entity that: (1) Is legally responsible for the operation of the food establishment such as the owner, the owner's agent, or other person; and (2) Possesses a valid permit to operate a food establishment) shall be the person in charge or shall designate a person in charge and shall ensure that a person in charge is present at the food establishment during all hours of operation. Designation of a person in charge during all hours of operations ensures the continuous presence of someone who is responsible for monitoring and managing all food establishment operations and who is authorized to take actions to ensure that the Code's objectives are fulfilled. During the day-to-day operation of a food establishment, a person who is immediately available and knowledgeable in both operational and Code requirements is needed to respond to questions and concerns and to resolve problems. In addition, The designated person in charge who is knowledgeable about foodborne disease prevention, Hazard Analysis and Critical Control Point (HACCP) principles, and Code requirements is prepared to recognize conditions that may contribute to foodborne illness or that otherwise fail to comply with Code requirements, and to take appropriate preventive and corrective actions. During a review of the FDA [Federal Food and Drug Administration] Food Safety.gov, last reviewed July 2020, the document indicated, Good food safety practices are vital in long term care facilities, as seniors are at an increased risk for hospitalization and death from foodborne illnesses. Seniors living in nursing homes face 10 times the risk of dying from bacterial gastroenteritis (an infection or inflammation in the stomach and intestine) than people in the community. The gastrointestinal tract (mouth, esophagus, stomach and intestines) holds onto food for a longer period of time, allowing bacteria to grow. The liver and kidneys may not properly rid the body of foreign bacteria and toxins. The stomach may not produce enough acid. The acidity helps to reduce the number of bacteria in our intestinal tract. Underlying chronic conditions, such as diabetes and cancer, may also increase a person's risk of foodborne illness. An immediate jeopardy (IJ) (immediate corrective action is necessary because the provider's noncompliance with one or more of those requirements has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a facility) was called on June 29, 2021 at 1:30 PM, under §483.60(a)(2) Staffing- If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services. The survey team verbally notified the Administrator of the IJ failure to have a full-time director of food and nutrition services. This failure led to unsanitary conditions in the kitchen that had the potential to cause food-borne illness to the highly susceptible residents who received food from the kitchen. The Corrective Action Plan (CAP) included the following: 1. The RD 2 Consultant will have responsibility to oversee the kitchen full-time starting June 29, 2021. 2. The RD 2 Consultant in-serviced Dietary Services Supervisor (DSS 1) and newly hired Dietary Services Supervisor (DSS 2) on maintaining proper sanitary conditions in the kitchen June 29, 2021. 3. The Administrator was in-serviced by, Chief Clinical Officer regarding F801 ensuring the facility is staffed with a qualified full-time Dietary Services Supervisor and/or full time Registered Dietician and proper sanitation in the kitchen. 4. Plan will be addressed at the next QAPI (Quality Assurance Performance Improvement) Meeting scheduled for June 30, 2021. The IJ was lifted on June 30, 2021 at 1:56 PM, in the presence of the Administrator, after an acceptable corrective action plan was provided and verified to be implemented by observation, interviews and record reviews

CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Food Safety (Tag F0812)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

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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 safe and sanitary food preparation and storage practices in the kitchen were implemented when: 1. The Facility didn't address the broken door sweep that the pest control company identified as a pest entry point and four dead mice were found in the oven stuck to a glue trap. Rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. 2. A glue trap in the dry storage was found with dead roaches. Insects are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces. 3. The walk-in refrigerator was not maintaining 41° Fahrenheit (a scale of temperature on which water freezes at 32° and boils at 212° under standard conditions) to prevent bacterial growth and toxin production in food that is time/temperature controlled for safety. 4. Floors behind the ice machine and under the food carts, under the three- compartment sink (three separate sink compartments, one for each step of the dish washing procedure: wash, rinse, and sanitize), under the shelf storing clean metal pots and pans and under the shelves in the dry storage had food debris and trash. The floor and baseboard under the convection oven had a sticky yellow residue and the floor under the two stoves had a black grime and rotting food. Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 5. The knobs on the stove and the front of the stove had a black grime, which had the potential to contaminate food. 6. The cabinet holding the coffee and juice machine had water damage and the edges were deteriorating, which made the surface not easily cleanable. 7. The food preparation sink did not have an air gap, which had the potential for back flow from the drain to contaminate the sink. 8. The area under the food preparation sink, that was adjacent to the clean utensil drawers was dirty with a thick film of brown grime. 9. The wall behind the three-compartment sink was repaired but not made smooth, this made the surface not easily cleanable. The facility's failure to ensure safe and sanitary conditions in the kitchen resulted in the likelihood of microorganisms that harbor foodborne pathogens to come in contact with residents' food which could cause food-borne illnesses to a population of 73 of 73 residents who received food from the kitchen and were medically compromised. Findings: 1. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021, at 8:04 AM, a glue trap was found in the oven with four dead mice. DSS 1 stated that she did not know that the mice were there. During an interview on June 29, 2021, at 8:13 AM, the Maintenance Supervisor (MS) stated that the pest control company comes monthly and performs the minimum frequency of pest control and more often if needed. The MS stated, the pest control company will check for roaches, rodents, possums and set exterior [NAME] traps. During an observation on June 29, 2021 at 9:49 AM, of the back door in the kitchen, leading outside, the door sweep was damaged, sunlight was visible inside from the bottom of the back door, allowing for pests to enter. During an interview on June 29, 2021, at 10:05 AM, the MS stated that the door sweep gets cracked at the door stop because staff have to prop the door open for deliveries. During an interview with the Registered Dietitian (RD 2) on July 1, 2021, at 9:08 AM, she stated that her expectation is that they do not find any pests and if they do, they should respond immediately. During a review of the report from the Pest Control Company, titled Service Summary Report, dated from March, 25, 2021, the inspection findings indicate that yesterday one of them (mice) was caught on one of our glue boards and was thrown away. During a review of the Pest Control Company reports, titled Service Summary Report, dated March 25, 2021 - June 21, 2021, Under Client Actions it indicates that, Action required: door sweep damaged/missing (kitchen). Replace door sweep. Kitchen receiving door has gaps allowing pest entry. Opened on 12/30/20. Action required: Door sweep damaged/missing (interior). Replace door sweep. Door by kitchen. Opened on March 17, 2020. During a review of the facility policy titled Sanitation: Miscellaneous Areas, dated 2018, the policy indicated that Fly and Vermin Control: all doors and windows must be properly screened. During a review of the FDA Federal Food Code 2017, indicated Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests. And Rodent bait shall be contained in a covered, tamper-resistant bait station. Open bait stations may result in the spillage of the poison being used. Also, it is easier for pests to transport the potentially toxic bait throughout the establishment. Consequently, the bait may end up on food-contact surfaces and ultimately in the food being prepared or served. During a review of the FDA Federal Food Code 2017, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 2. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021 at 8:20 AM, there was a sticky trap under the shelf in the dry storage room with five dead roaches. DSS 1 stated that staff should have discarded the trap. During an interview with the Registered Dietitian (RD 2) on July 1, 2021 at 9:08 AM, she stated that they should not have open sticky traps in the dry storage and as soon as pests are trapped, they should be removed. During a review of the FDA Federal Food Code 2017, Dead rodents, birds, and insects must be removed promptly from the facilities to ensure clean and sanitary facilities and to preclude exacerbating the situation by allowing carcasses to attract other pests. During a review of the FDA Federal Food Code 2017, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 3. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021, 8:08 AM, the walk-in refrigerator thermometer read 48° Fahrenheit, but should have been 41° Fahrenheit according to DSS 1. The refrigerator contained time/temperature controlled for safety food such as milk, cheese, yogurt, and meat. The temperature of a carton of milk was 49° Fahrenheit and the yogurt was found to be at 52° Fahrenheit. (Safe temperature should be at 41° Fahrenheit or below). The DSS 1 stated that the door to the refrigerator had been open because they just got a food delivery. During an observation on June 29, 2021 at 4:30 PM, the thermometer in the refrigerator read 45° Fahrenheit. The temperature of a milk was 48° Fahrenheit and a block of sliced cheese at 50° Fahrenheit. Safe refrigerator temperature of food is 41° Fahrenheit or below. During an interview with the Registered Dietitian (RD 2) on June 29, 2021 at 5:07 PM, she stated they had this same issue with the refrigerator on June 15th and they had the refrigerator serviced. She stated because they cannot determine if the refrigerator and the food lowered to 41° degrees during the time from 8:00 AM to 4:30 PM on June 29, 2021, they would need to discard all the TCS (time/temperature controlled for safety) foods. During a review of facility document titled Kitchen Sanitation and Food Safety Inspection, dated April 21, 2021, the Registered Dietitian (RD 2) reported that the freezer had frost around freezer door and on the floor- slipping hazard and seal at bottom of fridge door pulling away. A review of the FDA Federal Food Code 2017, indicates that Maintaining TCS (foods that require time and temperature control to prevent pathogen growth) foods under the cold temperature control requirements prescribed in this code will limit the growth of pathogens that may be present in or on the food and may help prevent foodborne illness and Except during preparation, cooking, or cooling ., time/temperature control for safety food shall be maintained: at 41° Fahrenheit or less. During a review of facility document titled Cold Storage Temperature Logging, dated 2018, indicates Refrigerator temperature standards are less or equal to 41° Fahrenheit. The goal is to keep the temperature at 34° - 39° Fahrenheit. This will allow for a 2° rise in temperature when the door is opened throughout the day. They will also keep the food at less than 41° Fahrenheit. 4. During an observation and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021 between 7:25 AM and 8:04 AM, floors behind the ice machine and under the food carts, under the three compartment sink, under the shelf storing clean metal pots and pans and under the shelves in the dry storage had food debris and trash. The floor and baseboard under the convection oven had a sticky yellow residue and the floor under two stoves had a black grime and rotting food. The DSS 1 stated that the floors should be kept clean. During an interview on July 1, 2021, at 9:08 AM, the Registered Dietitian (RD 2) stated that she was under the impression that the floor was being mopped after each meal. She stated that the person responsible for doing the cleaning was not doing a good job and the areas that she was responsible for were not getting done. She stated that she had identified some issues with temperatures of food on her last inspection in May 2021, so the cleanliness was not a high priority. She had talked to the previous Dietary Services Supervisor (DSS 2) about doing deep cleaning, but she was short staffed at the time and was getting things done slowly. She stated that her expectation was that there should be no food left on the floor and that the stove should be moved to clean under it. During a review of facility policy titled, General Appearance of Food & Nutrition Department, dated 2018, indicated that 1. Floors must be mopped at least once per day, 2. Sweep the floor, pushing all debris forward. Use a dust-pan to remove and dispose of debris as it accumulates . 7. Mop under and around equipment, along the walls and in corners. Wipe all splash and soil marks from baseboards and walls. During a review of the FDA Federal Food Code 2017, it indicated, Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. 5. During an observation in the kitchen on June 29, 2021 at 7:38 AM, the knobs on the stove that light the burners were covered in a black grime and the front of the stove around the knobs was covered in black grime. During an interview on July 1, 2021 at 9:08 AM, the Registered Dietitian (RD 2) stated that the stoves should be completely clean and not have any buildup. During a review of facility policy titled Ranges and Ovens, dated 2018, indicated, .3. Back apron of the range and other range surfaces should be washed with a hot detergent solution following manufacturer's instructions to remove grease. During a review of the FDA Federal Food Code 2017, indicates Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Also, The objective of cleaning focuses on the need to remove . soil from non-food contact surfaces so that pathogenic microorganisms will not be allowed to accumulate, and insects and rodents will not be attracted. During a review of the FDA Federal Food Code 2017, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 6. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 29, 2021, at 7:25 AM, the shelf that was holding the coffee maker and the juice machine had water damage and the edges were deteriorating. The DSS 1 stated that they planned to get that cabinet replaced. During an interview with the Registered Dietitian (RD 2) on July 1, 2021 at 9:08 AM, the RD 2 stated that she documented and put in a request in May 2021 to get the shelf replaced and the Administrator said he would get back to her. During an interview with the Administrator and concurrent record review of the Kitchen Sanitation & Food Safety Inspection, completed by the Registered Dietitian (RD 2) dated in May 2021, it indicated that the shelf holding the coffee maker and the juice machine needed to be replaced. The Administrator stated that he had gotten a quote to get it fixed but has not scheduled for the shelf to get replaced. Review of the facility policy titled Sanitation, dated 2018, indicated All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. During a review of the FDA Federal Food Code 2017, indicates Nonfood-contact surfaces shall be free of unnecessary ledges, projections, and crevices and designed and constructed to allow easy cleaning and to facility maintenance. Also, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. During a review of the FDA Federal Food Code 2017, Insects and other pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. Effective measures must be taken to eliminate their presence in food establishments. 7. During an observation in the kitchen on June 30, 2021, at 8:46 AM, the food preparation sink drain was directly connected to the sewer and did not have an air gap. During an interview with the Maintenance Supervisor (MS), on July 1, 2021, at 8:21 AM, the MS stated he did not know that the food preparation sink needed an air gap. During a review of the FDA Federal Food Code 2017, indicates A plumbing system shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the food establishment, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap as specified under 5-202.12. 5-202.13 indicated 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. In addition, During periods of extraordinary demand, drinking water systems may develop negative pressure in portions of the system. If a connection exists between the system and a source of contaminated water during times of negative pressure, contaminated water may be drawn into and foul the entire system. Providing an air gap between the water supply outlet and the flood level rim of the plumbing fixture or equipment prevents contamination that may be caused by backflow. 8. During an observation in the kitchen and concurrent interview with the Dietary Services Supervisor (DSS 1) on June 30, 2021, at 8:46 AM, the enclosed area under the food preparation sink was dirty with a thick layer of brown grime. This area is adjacent and open to the three drawers containing utensils for serving food. The DSS 1 stated that the utensils are clean and could be potentially contaminated by the dirty area adjacent. During an interview with the Registered Dietitian (RD 2) on July 1, 2021, at 9:08 AM, she stated that she expects that area to be clean and not have the potential to contaminate the clean utensils. Review of the facility policy titled Sanitation, dated 2018, indicates All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks and chipped areas. 9. During an observation in the kitchen on June 30, 2021, at 8:46 AM, the wall behind the three-compartment sink appeared to have been repaired. Some spackle was used to cover the edges, but the drywall was visible, and the wall was not smooth. It had lumps of spackle. During an interview on July 1, 2021, at 8:21 AM, the Maintenance Supervisor (MS), stated in the room behind the three-compartment sink, there used to be a beauty shop. The sink for the beauty shop water line was connected to the same line as the three-compartment sink. They turned that beauty shop into an office and removed the sink. He stated they did not do a good patch job. During a review of the FDA Federal Food Code 2017, indicates Non-food-contact surfaces shall be free of unnecessary ledges, projections, and crevices and designed and constructed to allow easy cleaning and to facility maintenance. Also, Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow the growth of foodborne pathogenic microorganisms. During a review of the Facility Census, dated June 29, 2021, it indicates that there were 73 residents. An immediate jeopardy (IJ) (immediate corrective action is necessary because the provider's noncompliance with one or more of those requirements has caused, or is likely to cause, serious injury, harm, impairment or death to a resident receiving care in a facility) was called on June 29, 2021 at 1:30 PM, under 483.60(i)(2) - Food Safety Requirements Store, prepare, distribute and serve food in accordance with professional standards for food service safety. The survey team verbally notified the Administrator of the IJ unsanitary conditions in the kitchen. Failure to maintain sanitary conditions in the kitchen had the potential to cause food-borne illness to the highly susceptible residents who received food from the kitchen. The Corrective Action Plan (CAP) included the following: 1 The integrity of the dry goods food was inspected and discarded as needed. 2. In-services were completed by RD 2 Consultant and will be on-going for all dietary staff related to maintaining safe and sanitary conditions of the kitchen. Cleaning of the kitchen will be completed at the beginning and end of the shift. Staff will be in-serviced on where the enclosed traps are located. 3. The sticky trap with 4 dead mice found inside the oven was immediately discarded. 4. The sticky trap in the dry storage with roaches was immediately discarded. 5. The floors under all shelves, and under food carts have food debris and trash were cleaned and trash removed. 6. The floors under the three-compartment sink with food debris were cleaned and trash removed. 7. The floors in the dry storage under shelves with food debris were cleaned and trash removed. 8. The floors under the two stoves and the convection oven with black grime and old food were cleaned. The whole red tomato found rotting under the stove was immediately discarded. 9. The baseboards behind the convection oven with a greasy sticky film and dirt was cleaned. 10. The two drawers storing clean serving utensils with food crumbs were cleaned. 11. The wall behind the dish sprayer spotted with food was cleaned. 12. The knobs on the stove to turn on the burners covered with grime were cleaned. 13. A thorough deep cleaning of the kitchen will be completed June 29, 2021. 14. A pest control company is scheduled to make a visit on June 29, 2021 at 4:00 PM to treat for rodent and roach control of the kitchen and the rest of the facility. The facility is changing pest control companies and the contracted pest control company will be on-site June 29, 2021 at 8:00 PM, and will continue to treat the facility every other week (or more often as needed) for the next six weeks. 15. Preventative measures to include fix kitchen door sweep June 29, 2021. Weekly review of the kitchen by Maintenance Staff will be conducted for any issues that need to be resolved. Pest control reports will be followed up by the Administrator to ensure findings are addressed. 16. A review of all residents will be conducted to monitor for any potential food-borne illness for the next three days. 17. Food temperatures in the refrigerator were obtained. Food items were found to be within acceptable range except for the dairy foods. The dairy food items were discarded and ordered June 29, 2021 to be delivered June 30, 2021. 18. Tuna sandwiches, three bean salad, milk (replaced from sister facility), thickened juice, ready care 2.0 (High calorie, high protein nutritional drink) for thicken milk, ice cream, and canned pasteurized pears (for puree diets) were served to residents for dinner. Pasta was also purchased as an alternative for patients. 19. The inner seal on the bottom half of the refrigerator was fixed to ensure the refrigerator door shut completely and with minimal effort. The refrigerator temperature will be checked every two hours to ensure 41 degrees Fahrenheit is maintained for the next 12-24 hours. The Refrigeration Specialist will be in to check the refrigerator tomorrow morning June 30, 2021. If it is determined that the refrigerator temperatures cannot be maintained and/or the refrigerator cannot be repaired, the refrigerator will be replaced with a new one. 20. The emergency menu will be used, which does not use refrigerated items, until it is determined that correct refrigerator temperature can be maintained. 21. A refrigerator will be purchased June 29, 2021 to maintain food which has sustained the correct holding (41° Fahrenheit or below) temperature. 22. The Plan will be addressed at the next QAPI (Quality Assurance Performance Improvement) Meeting scheduled for June 30, 2021. The IJ was lifted on June 30, 2021 at 1:56 PM, in the presence of the Administrator, after an acceptable corrective action plan was provided and verified to be implemented by observation, interviews and record reviews.

CONCERN (D)

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

Deficiency F0577 (Tag F0577)

Could have caused harm · This affected 1 resident

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Based on observation and interview, the facility failed to post the results of the most recent survey of the facility in a place readily accessible (a place where individuals wishing to examine survey results do not have to ask to see them.) to residents, and family members when six out of six residents (Residents 19, 40, 49, 57, 59, and 327) stated they did not know about the survey results binder, nor had they seen the survey results binder in the facility. This failure resulted in a violation of resident rights to examine any plan of correction in effect, to address identified concerns within the facility, receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. Findings: During an observation and interview on June 30, 2021 at 10:00 AM, during the Resident Council Meeting, six of six residents (Residents 19, 40, 49, 57, 59, and 327) raised their hand confirming that they did not know there was a survey results binder, nor had they seen the survey results binder in the facility. During an observation on July 1, 2021, at 10:32 AM, it was observed that the survey results binder was in a basket mounted on a wall behind the reception desk. The survey binder was not in a readily accessible location for resident examination. During an interview with the Director of Nurse's (DON) on July 1, 2021 at 10:32 AM, the DON stated that the survey results binder was found under the nurse's station desk. The DON further stated she did not know where the survey results binder for the residents to view was located. The DON stated she would have to ask the Administrator where that copy was kept. The copy of the survey results binder for resident viewing was observed to be on the wall in a basket behind the reception desk at the front of the facility. The DON stated that the binder would be given to the resident (s) if they asked for it.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician's order to apply bilateral heel protectors for one of three sampled Residents (Resident 32) to prevent skin breakdown due to immobility. This failure had the potential for pressure ulcers to form on the heels of Resident 32, who was already compromised and being treated for a Stage 3 (full thickness skin breakdown) pressure ulcer on his sacrum (area near tailbone). Findings: During an observation on June 29, 2021, at 4:38 PM, in Resident 32's room, Resident 32 was noted to not be wearing bilateral heel protectors. During an interview on June 29, 2021, at 4:39 PM, with the Treatment Nurse (TN), the TN stated, The heel protectors should be worn by the Resident, I'll find them. During a review of Resident 32's Order Summary Report (OSR), dated June 29, 2021, the OSR active orders indicated, Heel protectors to bilateral heels every shift to maintain skin integrity. During a review of Resident 32's Face Sheet (contains clinical and demographic information) for Resident 32, the Face sheet indicated, Resident 32 was admitted to the facility on [DATE], with diagnosis that included: stage 3 pressure ulcer of sacral region, muscle wasting (loss of muscle) and atrophy (decrease in muscle mass), and altered mental status. During a review of Resident 32's Treatment Administration Record (TAR), for the months of April, May, and June 2021, the TAR indicated missing documentation of heel protectors to bilateral heels every shift for the following dates: a. April 17, 2021, 11:00 PM - 7:00 AM b. April 18, 2021, 3:00 PM- 11:00 PM c. April 24, 2021, 3:00 PM-11:00 PM and 11:00 PM -7:00 AM d. April 27, 2021, 3:00 PM-11:00 PM e. May 9, 2021, 7:00 AM - 3:00 PM f. May 12, 2021, 7:00 AM - 3:00 PM and 11:00 PM -7:00 AM g. May 13, 2021, 11:00 PM -7:00 AM h. May 20, 2021, 7:00 AM - 3:00 PM i. May 30, 2021, 7:00 AM - 3:00 PM j. June 28, 29, and 30, 11:00 PM - 7:00 AM During a concurrent interview and record review, on July 1, 2021, at 11:27 AM, with a Licensed Vocational Nurse 2 (LVN 2), Resident 32's Treatment Administration Record (TAR), dated June 2021, was reviewed. When asked what the empty boxes indicated, LVN 2 stated, Task was not done. LVN 2 further stated, Nurses document if a task was completed. During a concurrent interview and record review on July 1, 2021, at 11:48 AM, with the Director of Nursing (DON), Resident 32's TAR, dated June 2021, was reviewed. DON stated, All provided treatments must be documented in the medical record. DON further stated, If it is not recorded, it's not done. During a concurrent interview and record review on July 1, 2021, at 11:50 AM, with the DON, of the facility's policy and procedure (P&P) titled, Positioning and Moving, Repositioning, revised May 2013, the P&P indicated, . information should be recorded in the resident's medical record the name and title of the individual who gave the care. The DON stated, Expectation is to document services or treatments provided.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to secure topical medications (used on a specific surface of the body) when the storage room that housed the medications was found to be unlocked. This had a potential to cause harm to residents who could easily access medications without the appropriate knowledge of their use. Findings: During a tour of the facility on June 10, 2021, at 5:51 AM, a storage room containing treatment supplies was noted to be unlocked. Topical medications within the storage room included Zinc Oxide, Sterile, Hydrocortisone Cream, Skin Protectant Ointment with Vitamins A&D, Silver Sulfadine Cream, Dakins Solution, Collagen Particles, Burn Dressing Honey, Hemorrhoidal Ointment, Calazinc Body Shield and Triple Antibiotic Ointment. During an interview on June 30, 2021, at 6:02 AM, with a Certified Nursing Assistant (CNA 4), when asked whether the treatment storage room is kept locked, she stated that they are kept locked. During an interview on June 30, 2021 at 6:04 AM, with a Licensed Vocational Nurse (LVN 5), when asked if the treatment supply room is kept locked, she stated that the linen closets are not always locked but the treatment supply closet is locked because of the medications that are kept in there. During an interview on June 30, 2021, at 6:12 AM, with the Director of Nursing (DON), when asked if the treatment supply room should be locked, she stated that the room should be locked because of the medications that are stored inside. She also stated that the treatment nurse or LVN on each shift are the only ones that have keys. During a record review on June 30, 2021, at 7:16 AM, of the facility policy titled Storage of Medications, section Policy Interpretation and Implementation, 1. Drugs and biologicals used in the facility are stored in locked compartments, .8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts and boxes) containing drugs and biologicals are locked when not in use.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide two residents with adequate protein per the planned menu. This failure had the potential to not provide the nutrients needed for adequate nutrition. Findings During an observation on June 29, 2021, at 11:55 AM, of the staff plating the meals, the [NAME] placed a small turkey slice on two plates. The Surveyor asked the cook to weigh the slice of turkey. The turkey slice weighed 1.9 ounces. The Dietary Services Supervisor (DSS) instructed her to add two slices of turkey per plate. During an interview with the Registered Dietitian, on July 1, 2021, at 9:08 AM, she stated that she expects staff to follow the menu and her practice is more is better. During a review of the facility document titled Summer Menu: Cooks Spreadsheet, dated June 28, 2021, indicated for lunch the regular diet should receive 3 ounces of roast turkey.

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 proper disposal of garbage and refuse when the garbage area was littered with trash, old food containers, leaves and dirt. This failure had the potential to attracts pests. Findings: During an observation and concurrent interview with the Maintenance Supervisor (MS) on June 29, 2021, at 9:52 AM, the garbage area outside the back door of the kitchen had trash, old food containers, leaves and dirt all over the ground. The MS stated the area should be kept clean and there should not be any trash on the floor. During an interview with the Registered Dietitian, on July 1, 2021, at 9:08 AM, she stated the garbage area should be free of trash on the ground and the lids to the dumpster should be closed. During a review of facility policy, titled Miscellaneous Areas: Garbage and Trash, dated 2018, indicated Trash Collection Area: The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. 1. The area must be swept and washed down by maintenance with a detergent on a regular basis. During a review of the FDA Federal Food Code 2017, 5-501.113, Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on June 29, 2021, at 10:39 AM, in the nurse station, Resident 3 was observed sitting on her wheel chair, receiving oxygen from an oxygen tank (a metal tank containing pressurized oxygen), which provides oxygen to resident via nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils). The nasal cannula was in use and had no date written on it to indicate when it had been replaced. During a concurrent observation and interview on June 29, 2021, at 10:45 AM, with a License Vocational Nurse 1 (LVN 1), in the nurses' station, she acknowledged that Resident 3's oxygen nasal cannula was not dated. LVN 1 stated that nasal cannula should be dated when it was changed weekly. During an interview on June 29, 2021, at 3:51 PM, with the License Vocational Nurse/ Infection Preventionist (LVN/ IP), he stated that oxygen nasal cannulas are changed every week and the date should be written on it. During a review of Resident 3' clinical records, the face sheet (containing demographic information), indicated Resident 3 was admitted on [DATE], with diagnoses which included, Chronic Obstructive Pulmonary Disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). During a concurrent interview and record review on July 1, 2021, with Director of Nursing (DON), the document titled Order Summary Report (which contains Physicians orders), dated July 1, 2021, was reviewed. The Order Summary Report indicated Resident 3 had an order for Change bubble humidifier, humidifier tubing, nasal cannula, and setup bag (date all equipment) . every Sunday. The order status was active with a start date of May 10, 2021. The DON stated if the order specified that equipment was to be dated, the staff who was in charge of changing the oxygen nasal cannula must date it. During a review of the facility's policy and procedure titled, Oxygen Administration, revised October 2010, indicated, . 1.c.The oxygen tubing, mask, nasal cannula will be changed every 7 days . Based on observation, interview, and record review, the facility failed to ensure that two sets of oxygen tubing were labeled with the date they were put into use for two of 73 residents, Resident 45 and Resident 3. This failure had the potential to cause respiratory infection to Residents 45 and 3. Findings: 1. During an observation on June 29, at 8:27 AM, on initial tour, there was an oxygen concentrator at the bedside of Resident 45, with no date on the tubing. During an interview on June 29, 2021, at 9:05 AM, with a Licensed Vocational Nurse (LVN 1), LVN 1 stated the tubing for the oxygen should be labeled with a date indicating the date tubing was placed on the concentrator. During an interview on June 29, 2021, at 1:00 PM, with the Infection Preventionist (LVN/IP), the LVN/IP stated the oxygen tubing is changed weekly, and should be dated when changed. During a review of the clinical record for Resident 45, the Physician Order's indicated, Oxygen at 2L (liters per minute) via Nasal Cannula as needed . During a review of the facility policy and procedure (P&P) titled Oxygen Administration revised October 2010, the P&P indicated, .1.c. The oxygen tubing .will be changed every 7 days and/or as needed .

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** Based on observation, interview, and record review the facility failed to ensure two of nine showers (Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER]) were safe and sanitary in a universe of 73 Residents when two shower rooms were not clean and in need of repairs as follow. 1. Shower room [ROOM NUMBER]'s shower floor had 'dirt' black material around the edges of the shower, there was a broken tile on the wall of the shower at the level of the floor, there was a hole in the wood door frame inside the shower room, and the drain cover was not secured to the drain. 2. Shower room [ROOM NUMBER]'s shower floor had 'dirt' black material around the edges of the shower and there were cracked tiles on the wall of the shower at the level of the floor. There was water leaking from the right water control knob These failures had the potential to cause harm to residents using the shower room. Findings: During an observation on June 29, 2021, at 7:54 AM, in Shower room [ROOM NUMBER], it was observed that the shower floor had black material on the edges of the shower floor and first row of tiles. There were cracked tiles in the first row of tiles in the shower above the floor. There was water leaking from the right water control knob. During an observation on June 30, 2021, at 5:10 AM, in Shower room [ROOM NUMBER], it was observed that the shower floor had black material around the edges of the shower, there was a broken tile on the wall of the shower at the level of the floor, there was a hole in the wood door frame inside the shower room, and the drain cover was not secured to the drain. During an observation and interview on June 30, 2021, at 9:32 AM, with the Maintenance Supervisor (MS), the MS observed Shower room [ROOM NUMBER] and stated that the black material on the shower floor edges was 'dirt'. The MS stated he observed the hole in the wall and that it was probably due to a wheelchair hitting it. The MS further stated he knew about the door jam damage and side it wasn't a 9-1-1 issue; I will get to it. During an observation and interview on July 1, 2021, at 7:47 AM, with the Director of Nurse's (DON), the DON observed Shower room [ROOM NUMBER]. The DON stated there was black material on the floor of the shower but didn't know what it was. She further observed and agreed that the broken tile at the floor of the shower was a safety hazard. The DON observed the hole in the wood of the door frame and stated she did not know there was a hole. The DON observed the drain cover not secured to the drain in the shower. She stated that should be secured. She touched the inside of the door to Shower room [ROOM NUMBER] and stated there was some kind of film on the door. During an interview on July 1, 2021, at 8:10 AM with the Maintenance Supervisor (MS) in Shower room [ROOM NUMBER], the MS observed that the right knob for water flow was leaking. He further observed the drain cover not secured to the drain hole. The MS stated he agreed the drain cover should be secured to the drain. He further stated he did not know the water was leaking and agreed that it needed to be repaired. During an interview on July 1, 2021, at 10:38 AM, with Housekeeper 1, Housekeeper 1 stated she cleaned the bathroom once a day. She further stated she sprays and cleans all the walls and floor in the showers and bathroom. There was no visual evidence that Shower room [ROOM NUMBER] and Shower room [ROOM NUMBER] had been cleaned. During a review of the Maintenance Repair Log, dated January 31, 2021 through July 1, 2021, indicated there was no documented evidence that the black material was reported, the drain covers not secured were reported, the hole in the wood door frame was reported, the broken tile in the shower was reported and the leaking water control knob was reported. During a review of Daily Housekeeping Procedures, undated, it indicated the Housekeeper was to Disinfect all shower chairs, wipe all surfaces throughout shower room (hand rails, walls, bathroom dividers), remove sharp containers, clean tiles/grout, empty trash sweep, and mop. There was no visual evidence that the tiles/grout were cleaned. During a review of a calendar for facility Deep Cleaning June 2021, it indicated there was no documented evidence for scheduled deep cleaning of shower rooms. During a review of the facility policy titled, Maintenance Service, dated revised 2009, it indicated, Functions of maintenance personnel include, but are not limited to: . b. Maintaining the building in good repair and free from hazards.

CONCERN (F)

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

Room Equipment (Tag F0908)

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 maintain the following essential kitchen equipment in safe operating condition when; 1. The walk-in refrigerator was not maintaining appropriate temperature, which caused the time/temperature controlled for safety (TCS) food ( foods that require time or temperature control to limit pathogenic microorganism growth or toxin formation) to not maintain safe temperature. 2. The freezer had ice build-up all over the floor, which means it was not functioning properly and could affect the integrity of the food. 3. The oven of one of the kitchen ranges did not work and the second range had an oven and grill top that was not functioning, which led to these unused equipment harboring pests that could potentially contaminate other equipment and food. These failures had the potential to lead to food borne illness in a medically compromised population of 73 residents who received food from the kitchen. Findings: 1. During an observation and concurrent interview with the Dietary Services Supervisor (DSS) on June 29, 2021, 8:08 AM, the walk-in refrigerator thermometer read 48° Fahrenheit but should have been 41° Fahrenheit or below. The refrigerator contained time/temperature controlled for safety food such as milk, cheese, yogurt and meat. The Surveyor tested the temperature of a carton of milk at 49° Fahrenheit and yogurt at 52° Fahrenheit. The DSS stated that the door to the refrigerator had been open because they just got a food delivery. During an observation on June 29, 2021 at 4:30 PM, the thermometer in the refrigerator read 45° Fahrenheit. The Surveyor checked the temperature of a milk at 48° Fahrenheit and a block of sliced cheese at 50° Fahrenheit. During a concurrent observation and interview on June 29, 2021, at 4:39 PM, with the Maintenance Supervisor, he rechecked the refrigerator temperature using his gun thermometer and found it to be 53° Fahrenheit. He stated that the last person that came out to look at the refrigerator said that the excessive heat outside could cause the refrigerator to not function properly. During an interview with the Registered Dietitian on June 29, 2021, at 5:07 PM, she stated the refrigerator was not maintaining temperature on June 15th and they had the refrigerator serviced. She stated, because they cannot determine if the refrigerator and the food lowered to 41° degrees during the time from 8:00 AM to 4:30 PM, they would need to discard all the time/temperature controlled for safety food. During an interview with the Maintenance Supervisor on July 1, 2021, at 8:08 AM, he stated that he has no regular scheduled maintenance done for the refrigerator. He will call a vendor out to fix it when issues arise. During a review of the facility policy, titled Refrigerator and Freezer, dated 2018, indicated How to keep your refrigerator and freezer working efficiently: . 2. Periodically, check door gaskets and replace if damaged. 3. Clean the evaporator and condensing coils at least twice a year 4. At least once a year, ensure that drain lines are clean and all electrical connections are intact. 5. Make sure to maintain clear and adequate airflow on outside condensing units . During a review of the manufacturer's manual for the refrigerator and freezer, titled Service Manual Walk-in Coolers and Freezer, dated 2013, indicated Routine Maintenance: . D. Heater wires should be checked for proper function . F. Inspect refrigeration units frequently for proper function of evaporator & condenser fan motors, drain pan heaters, defrost controls and drain line heaters. According to the 2017 Federal Food and Drug Administration (FDA) Food Code 2017, indicates Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. 2. During the initial kitchen tour observation on June 29, 2021 at 8:13 AM, the walk-in freezer had ice build-up on the floor and a pile of ice build-up in the right corner under the blower. This freezer contained TCS foods such as meat and frozen vegetables. During an interview with the Maintenance Supervisor (MS) on July 1, 2021, at 9:01 AM, he stated that he does not do any preventative maintenance on the freezer. He stated that the kitchen staff did not notify him of the ice build-up in the freezer. During an interview and concurrent record review of the document titled Kitchen Sanitation and Food Safety Inspection, dated April 21, 2021, with the Registered Dietitian on July 1, 2021 at 9:08 AM, she stated that they should be doing regular maintenance to the refrigerator and freezer as required by the standard. She stated that she identified the frost build-up in the freezer in her April report. During a review of the facility policy, titled Refrigerator and Freezer, dated 2018, indicated How to keep your refrigerator and freezer working efficiently: .2. Periodically, check door gaskets and replace if damaged. 3. Clean the evaporator and condensing coils at least twice a year 4. At least once a year, ensure that drain lines are clean and all electrical connections are intact. 5. Make sure to maintain clear and adequate airflow on outside condensing units . During a review of the manufacturer's manual for the refrigerator and freezer, titled Service Manual Walk-in Coolers and Freezer, dated 2013, indicates Routine Maintenance: .F. Inspect refrigeration units frequently for proper function of evaporator and condenser fan motors, drain pan heater, defrost controls and drain line heaters. Condensate water mush never be permitted to drip on the walk-in floor. Drain pan or drain line heater failure will result in ice buildup and evaporator damage. According to the 2017 Federal Food and Drug Administration (FDA) Food Code 2017, indicates Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk. For example, refrigeration units in disrepair may no longer be capable of properly cooling or holding time/temperature control for safety foods at safe temperatures. 3. During an observation on June 29, 2021, at 8:04 AM, four dead mice were found on a sticky trap inside the oven of one of the ranges. The Dietary Services Supervisor (DSS) stated that the oven was not functioning, they currently only use the stove top. She stated the second range is not working at all and they just use it as a work surface. The DSS stated that she has only worked here for a few days and was not sure when the ranges stopped working. During an interview on July 1, 2021, at 8:08 AM, the Maintenance Supervisor stated that he was not aware the ranges were not working, because kitchen staff did not report it to him. When asked about the process of reporting any defective equipment from the kitchen, he stated that the Kitchen staff should document it, report it to him or inform him via text. During an interview on July 1, 2021, at 10:00 AM, the Director of Nursing (DON) stated that preventative maintenance on the ranges should be done as its required. She stated that since they had a separate convection oven that was working, they had more time to arrange to get them fixed. During a review of the FDA Federal Food Code 2017, indicates The presence of unnecessary articles, including equipment which is no longer used, makes regular and effective cleaning more difficult and less likely. It can also provide harborage for insects and rodents. And Insects and rodents are vectors of disease-causing microorganisms which may be transmitted to humans by contamination of food and food-contact surfaces.

CONCERN (F)

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

Deficiency F0925 (Tag F0925)

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 maintain an effective pest control program so that the facility was free of pests and rodents when: 1. The back door sweep was not repaired 2. Old food was found rotting under the stove 3. The floors throughout the kitchen were found with food debris and trash and a sticky trap was found in the dry storage with dead roaches. 4. Two non-functioning ranges were kept in the kitchen, one which had a sticky trap with four dead mice. 5. The garbage area outside was littered with trash, old food containers and leaves. These failures created an environment that attracted pests and had the potential to contaminate food and equipment. Findings: 1. During an observation on June 29, 2021 at 9:49 AM, in the kitchen, the back door leading outside, the door sweep was damaged, sunlight was visible inside from the bottom of the back door, allowing for pests to enter. During an interview on June 29, 2021, at 10:05 AM, the Maintenance Supervisor (MS) stated that the door sweep gets cracked at the door stop because staff have to prop the door open for deliveries. He stated he has fixed the door sweep but it keeps getting cracked. During a review of the report from the Pest Control Company, titled Service Summary Report, dated March, 25, 2021, the inspection findings indicated that yesterday one of them (mice) was caught on one of our glue boards and was thrown away. Under Client Actions it indicates that Action required: door sweep damaged/missing (kitchen). Replace door sweep. Kitchen receiving door has gaps allowing pest entry. Opened on December 30, 2020. Action required: Door sweep damaged/missing (interior). Replace door sweep. Door by kitchen. Opened on March 17, 2020. During a review of the report from the Pest Control Company, titled Service Summary Report, dated April 22, 2021, Under Client Actions it indicates that, Action required: door sweep damaged/missing (kitchen). Replace door sweep. Kitchen receiving door has gaps allowing pest entry. Opened on December 30, 2020. Action required: Door sweep damaged/missing (interior). Replace door sweep. Door by kitchen. Opened on March 17, 2020. During a review of the report from the Pest Control Company, titled Service Summary Report, dated May 26, 2021, Under Client Actions it indicates that, Action required: door sweep damaged/missing (kitchen). Replace door sweep. Kitchen receiving door has gaps allowing pest entry. Opened on December 30, 2020. Action required: Door sweep damaged/missing (interior). Replace door sweep. Door by kitchen. Opened on March 17, 2020. During a review of the report from the Pest Control Company, titled Service Summary Report, dated June 21, 2021, Under Client Actions it indicates that, Action required: door sweep damaged/missing (kitchen). Replace doorsweep. Kitchen receiving door has gaps allowing pest entry. Opened on December 30, 2020. Action required: Door sweep damaged/missing (interior). Replace door sweep. Door by kitchen. Opened on March 17, 2020. 2. During an observation on June 29, 2021, at 8:04 AM, under the stove to the right, there was a whole tomato rotting and the floor was covered in a black grime. During an interview with the Registered Dietitian, on July 1, 2020, at 9:08 AM, she stated there should be no food on the floor and the oven should have been moved to clean under it. 3. During an observation and concurrent interview with the Dietary Services Supervisor on June 29, 2021, at 7:25 AM, the floor under the ice machine and where the food carts were stored was with food particles and dirt. The DSS stated that the floors should be kept clean. During an observation on June 29, 2021, at 7:38 AM, the floor under the three compartment sink was dirty with debris and trash. The floor under the metal rack that contained clean pots and pans had food debris and dirt. The baseboard had a sticky yellow residue. The floor under the convection oven was dirty with a greasy residue. The floors under the two stoves had a black grime. During an observation and concurrent interview with the Dietary Services Supervisor (DSS) on June 29, 2021 at 8:20 AM, there was a sticky trap under the shelf in the dry storage room with multiple dead roaches. 4. During an observation on June 29, 2021, at 8:04 AM, four dead mice were found on a sticky trap inside the oven of one of the ranges. The Dietary Services Supervisor (DSS) stated that the oven is not functioning, they currently only use the stove top. She stated the second range is not working at all and they just use it as a work surface. The DSS stated that she has only worked here for a few days and is not sure when the ranges stopped working. 5. During an observation and concurrent interview with the Maintenance Supervisor (MS) on June 29, 2021, at 9:52 AM, the garbage area outside the back door of the kitchen had trash, old food containers, leaves and dirt all over the ground. The MS stated the area should be kept clean and there should not be any trash on the floor. During a review of facility policy titled Garbage and Trash, dated 2018, indicates Fly and Vermin Control: 1. All doors and windows must be properly screened . 3. The Food and Nutrition Services Department must be kept free of soil and clutter. During a review of the FDA Federal Food Code 2017, indicates Cleanliness of the food establishment is important to minimize attractants for insects and rodents, aid in preventing the contamination of food and equipment, and prevent nuisance conditions. Also The presence of unnecessary articles, including equipment which is no longer used, makes regular and effective cleaning more difficult and less likely. It can also provide harborage for insects and rodents. In addition, Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · 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 meet the required square footage (sq./ft.) for two rooms (rooms [ROOM NUMBERS]). This failure had the potential to limit freedom of movement and affect the health and safety of four residents who reside in these rooms. Findings: During an observation and interview with the Maintenance Supervisor (MS), on June 30, 2021 at 9:10 AM, two rooms were measured and found to be less than the require 80 square feet per resident as follows: a. room [ROOM NUMBER] (two beds) measured: 146 sq./ft. = 73 sq./ft. per resident b. room [ROOM NUMBER] (two beds) measured: 143 sq./ft. =71.5 sq./ft. per resident During the survey conducted on June 29, 2021 through July 1, 2021, all residents in the above listed rooms were observed to utilize the space available. There were no complaints verbalized by the residents residing in the rooms regarding the room sizes. During an interview on June 30, 2021, 9:10 AM, with the MS, the MS stated he measured the rooms, but did not know the exact amount of space each resident required. He knew the rooms were small and they needed a waiver. The MS further stated he did not know if the facility had submitted a waiver for the year 2021. During an interview on June 30, 2021, at 3:00 PM, with the Administrator, when asked, about submitting the current year's room waiver for resident rooms [ROOM NUMBERS], the Administrator stated, We were unable to find it. The Administrator further stated he knew a waiver was required annually and the facility had not applied for a waiver for year 2021.

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

"What changes have you made since the serious inspection findings?"
"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: 3 life-threatening violation(s), 1 harm violation(s), $31,899 in fines, Payment denial on record. Review inspection reports carefully.
• 41 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $31,899 in fines. Higher than 94% of California facilities, suggesting repeated compliance issues.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 3 Immediate Jeopardy findings. Serious concerns require careful evaluation.

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About This Facility

What is Yucaipa Hills Post Acute's CMS Rating?

CMS assigns YUCAIPA HILLS 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 Yucaipa Hills Post Acute Staffed?

CMS rates YUCAIPA HILLS POST ACUTE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the California average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.

What Have Inspectors Found at Yucaipa Hills Post Acute?

State health inspectors documented 41 deficiencies at YUCAIPA HILLS POST ACUTE during 2021 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 35 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Yucaipa Hills Post Acute?

YUCAIPA HILLS POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 82 certified beds and approximately 78 residents (about 95% occupancy), it is a smaller facility located in YUCAIPA, California.

How Does Yucaipa Hills Post Acute Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, YUCAIPA HILLS POST ACUTE's overall rating (2 stars) is below the state average of 3.1, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Yucaipa Hills Post Acute?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the facility's high staff turnover rate, and the below-average staffing rating.

Is Yucaipa Hills Post Acute Safe?

Based on CMS inspection data, YUCAIPA HILLS POST ACUTE has documented safety concerns. Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Yucaipa Hills Post Acute Stick Around?

Staff turnover at YUCAIPA HILLS POST ACUTE is high. At 60%, the facility is 14 percentage points above the California average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Yucaipa Hills Post Acute Ever Fined?

YUCAIPA HILLS POST ACUTE has been fined $31,899 across 2 penalty actions. This is below the California average of $33,398. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Yucaipa Hills Post Acute on Any Federal Watch List?

YUCAIPA HILLS 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: 82
Avg. Residents: 78
Occupancy: 95.4%
Ownership: For profit - Limited Liability company
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
High Turnover: -5
3 Immediate Jeopardy citations: -36
1 Actual Harm citation: -5
41 Deficiencies: -10
Fines ($31,899): -5
Final Score: 0/100

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056365