Every finding on record at Chinese Hospital D/P SNF

Based on interview and record review, the facility failed to ensure three of six sampled residents (Residents 26, 14, and 15) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when:1. For Resident 26, there was no specific target behavior monitoring for the use of Lorazepam (medication used to treat anxiety) and2. For Residents 14 and 15, there was no diagnosis and/or specific condition for the use of antipsychotic medication.These deficient practices had the potential for residents to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.1. Resident 26 was admitted on [DATE] with diagnoses including sepsis (a life-threatening emergency caused by the body's extreme, harmful response to infection, often leading to rapid organ failure and death), hypertension (high blood pressure), and malnutrition. Review of Resident 26's Order Summary Report (OSR) for the month of February 2026 indicated, .Lorazepam Oral Tablet 1 mg (milligram) Give 1 tablet by mouth every 24 hours as needed for insomnia. Order Start Date 2/13/26. Review of Resident 26's Medication Administration Record (MAR), dated 2/1/26 to 2/28/26 indicated, .Monitor for the following behaviors: restlessness, clinical worsening, suicidality, unusual changes in behavior or serotonin syndrome (hallucinations, seizures, abnormal heartbeat, confusion, agitation). The behavior monitoring did not specify the medication it was monitoring for. Review of Resident 26's MAR dated 2/1/26 to 2/28/26 indicated, .Lorazepam Oral Tablet 1 mg (milligram) Give 1 tablet by mouth every 24 hours as needed for insomnia. was administered on 2/13/26. During a concurrent interview and record review on 2/25/26 at 2:57 PM with Consultant Pharmacist (CP), Resident 26's MAR was reviewed. CP confirmed that there was no specific target behavior monitoring for the use of Lorazepam for Resident 26. CP stated, It's not specific for Lorazepam. 2. A concurrent interview and review of Resident 15's medical records was conducted on 2/24/26 at 1:59 PM with the Director of Staff Development (DSD). Review of Resident 15's medical records titled Order Summary Report, for February 2026, indicated Resident 15 had a physician order for .Paliperidone Palmitate. for schizoaffective (once a month injection to be administered at a clinic). Paliperidone palmitate is a medication used to treat the symptoms of mental disorders, including schizophrenia. Schizophrenia is a mental health condition presenting with hallucinations (seeing or hearing things that are not there), delusions (false belief not based in reality), or disorganized thinking. Schizoaffective disorder is a chronic mental health condition that combines symptoms of schizophrenia with a mood disorder (like severe depression-profound hopelessness and loss of interest in activities, bipolar-elevated mood followed by severe depression). Review of Resident 15's medical records titled Diagnosis Report, for February 2026, found no diagnosis to support the use of paliperidone palmitate. The DSD was asked to search Resident 15's records for any documentation supporting the use of paliperidone palmitate. After searching, the DSD stated she could not find any clinical rationale(s) supporting the use of paliperidone palmitate. A concurrent interview and review of Resident 14's medical records was conducted on 2/24/26 at 2:19 PM with the DSD. Review of Resident 14's medical records titled Order Summary Report, for February 2026, indicated Resident 14 had a physician order for Quetiapine Fumarate . 25 mg (milligram a unit of weight measurement).two times a day for.mood disturbances/visual hallucination. Quetiapine is used to treat schizophrenia (a mental illness that affects how a person thinks, feels and behaves), bipolar disorder (a disease that causes depression, mania, and other abnormal moods) and major depressive disorder. Review of Resident 14's medical records titled Diagnosis Report, for February 2026, found no diagnosis to support the use of quetiapine. The DSD was asked to search Resident 14's records for any documentations supporting the use of quetiapine. After searching, the DSD stated she could not find any clinical rationale(s) supporting the use of quetiapine. On 2/25/26 at 12:20 PM, the [NAME] President of Quality (VPQ) was asked to provide documented evidence to support the use of paliperidone palmitate for Resident 15 and the use of quetiapine for Resident 14. Specifically, the requested documents included but was not limited to: admission summary from prior facility documenting diagnosis, conditions, specific behaviors that would support the use of these psychoactive medications. Physician assessment addressing diagnosis, conditions, behaviors regarding the use of these psychoactive medications Psychiatric assessment addressing diagnosis, conditions, behaviors regarding the use of these psychoactive medications Non-pharmacological interventions to address schizoaffective type behaviors for Resident 15 and mood disturbances/visual hallucinations type behaviors for Resident 14. Review of the documents sent by the VPQ found no supporting documentation for the use of paliperidone palmitate for Resident 15 and the use of quetiapine for Resident 14. Review of the facility's policy titled PSYCHOTROPIC MEDICATION USE POLICY – Skilled Nursing Facility (SNF) Unit, revised on 12/25, indicated . Indication for use: psychotropic medication will be determined to be necessary to treat a specific condition with diagnosis or indication documented in the medical record.

Based on observation, interview, and record review the facility failed to develop care plans for Residents 1, 14, 15, and 26, four residents out of a total sample of 8 residents. These were the areas the facility failed to care plan:Resident 15- antipsychotic medicationResident 1- anti-anxiety medication Resident 26- anti-anxiety medicationResident 14- bed railsThese failures had the potential to negatively impact these residents' health and safety.1. A concurrent interview and review of Resident 15's medical records was conducted on 2/24/26 at 1:59 PM with the Director of Staff Development (DSD). Review of Resident 15's medical records titled Order Summary Report, for February 2026, indicated Resident 15 had a physician order for .Paliperidone Palmitate. for schizoaffective (once a month injection to be administered at a clinic). Paliperidone palmitate is a medication used to treat the symptoms of mental disorders, including schizophrenia. Schizophrenia is a mental health condition presenting with hallucinations (seeing or hearing things that are not there), delusions (false belief not based in reality), or disorganized thinking. Schizoaffective disorder is a chronic mental health condition that combines symptoms of schizophrenia with a mood disorder (like severe depression-profound hopelessness and loss of interest in activities, bipolar-elevated mood followed by severe depression). Review of Resident 15's medical records titled Care Plan Report, dated admission date 02/04/2026, found no care plans addressing the use of paliperidone palmitate or schizoaffective disorder. 2. Review of Resident 1's face sheet indicated Resident 1 was admitted and placed in hospice (medical care for people who are expected to live six months or less) on11/28/25 for severe protein-calorie malnutrition (refers to various degrees of nutritional disorders caused by inadequate quantities of protein and energy in the diet). Review of Resident 1's physician orders for February 2026 indicated a prescription for Lorazepam (medication used to treat anxiety [a feeling of intense nervousness]) oral tablet 0.5 mg (milligram). Give 1 (one) tablet by mouth every 4 (four) hours as needed for anxiety manifested by agitation/ restless [sic], with a start date of 2/16/26 and an end date of 3/01/26. During a concurrent interview and record review on 2/25/26 at 1:40 PM, Registered Nurse (RN) 1 confirmed Resident 1's order for Lorazepam and stated, It's a psychotropic medication (any drug that affects behavior, mood, thoughts, or perception) .If he (Resident 1) has agitation, we can give it. RN 1 further stated, If it's (Lorazepam) ordered.supposed to have a care plan. During further review of Resident 1's electronic and paper-based care plan provided by the hospice agency, RN 1 was unable to find a care plan addressing anxiety or the use of Lorazepam. RN 1 stated, I can't find it. I don't know if he has it. I'm just per diem here. Better to ask a regular nurse. During a concurrent interview and record review on 2/25/26 at 2:24 PM, RN 2 reviewed Resident 1's care plan. RN 2 confirmed there was no care plan for anxiety or the use of Lorazepam. During a concurrent interview and record review on 2/25/26 at 3:20 PM, the Nurse Manager (NM) confirmed Resident 1 had an order for Lorazepam but could not find a care plan addressing anxiety or the medication. The NM stated, He should have it. Whenever there's an order for psychotropic medication, there should be a care plan for it. 3. Resident 26 was admitted on [DATE] with diagnoses including sepsis (a life-threatening emergency caused by the body's extreme, harmful response to infection, often leading to rapid organ failure and death), hypertension (high blood pressure), and malnutrition. Review of Resident 26's Order Summary Report (OSR) for the month of February 2026 indicated, .Lorazepam Oral Tablet 1 mg Give 1 tablet by mouth every 24 hours as needed for insomnia. Order Start Date 2/13/26. Review of Resident 26's Medication Administration Record (MAR), dated 2/1/26 to 2/28/26 indicated, .Lorazepam Oral Tablet 1 mg Give 1 tablet by mouth every 24 hours as needed for insomnia. was administered on 2/13/26. During a concurrent interview and record review on 2/25/26 at 2:41 PM with Registered Nurse (RN) 2, Resident 26's orders and care plans were reviewed. RN 2 acknowledged that Resident 26 had an order for Lorazepam. RN 2 confirmed that there was no care plan for the use of Lorazepam. RN 2 stated, I don't see it. No care plan for the use of Lorazepam. RN 2 also said to use non-pharmacological interventions first and the use of Lorazepam is the last recourse. 4. Resident 14 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe) and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred). During an observation on 2/25/2026 9:38 AM, Resident 14 was asleep in bed, with both upper bed rails up. During a concurrent interview and record review on 2/25/26 at 10:12 AM with RN 2, Resident 14's care plans were reviewed. RN 2 said Resident 14 used the bed rails as enabler for turning and repositioning. RN 2 confirmed there was no care plan for the use of bed rails, and stated, No care plan for the use of bed rails. I will put it in. RN 2 further stated, It could be considered as a restraint so it is important to make sure it's for mobility. Review of facility policy and procedure titled, Development and Implementation of Baseline and Comprehensive Care Plan, dated 9/23, indicated, Purpose: It is our purpose to ensure that each resident is provided with individualized, goal-directed care, which is reasonable, measurable and based on resident needs.Procedure: 1. Every resident will have an Interdisciplinary Care Plan.Developing the Care Plan.2. The care plan will include measurable objectives and timeframes to meet the resident's medical, nursing, pharmaceutical, mental and psychosocial needs that are identified in the comprehensive assessment.

Based on observation, interview, and record review, the facility failed to obtain a physician's (MD) order for oral suctioning for one of one sampled resident (Resident 14).This failure had the potential for Resident 14 not to receive appropriate treatment and services.Resident 14 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe) and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred).During an observation on 2/23/26 at 10:22 AM, Resident 14 was asleep in bed, oral suctioning equipment was at resident's bedside table. The canister contained light yellowish secretions.During an interview on 2/25/26 at 10:44 AM, Hospital Aide (HA) 1 said that the oral suctioning equipment was used to suction secretions of Resident 14. HA 1 stated, I do the suctioning when needed.Review of Resident 14's care plan indicated, .Focus: Resident 14 has altered respiratory status and difficulty breathing.Interventions/Tasks.Maintain a clear airway.If secretions cannot be cleared, suction as ordered/required to clear secretions.Review of Resident 14's clinical record, the Order Summary Report (OSR), active orders as of 1/1/126, the OSR did not indicate an order for oral suctioning.During a concurrent interview and record review on 2/26/26 at 11:02 AM with Nurse Manager (NM), Resident 14's orders were reviewed. NM acknowledged that there was no MD order for oral suctioning, and stated, I don't see one for oral suctioning. Furthermore, NM stated, There's a reason MD writes an order. We can't do anything without a doctor's order.Review of facility's policy and procedure (P&P) titled, Suction Policy and Procedure - SNF, dated 8/27/24, the P&P indicated, .routine suctioning does require a provider order.

Based on interview and record review, the facility failed to send notification to Ombudsman for one of two residents (Resident 24) when Resident 24 was discharged from the facility against medical advice (AMA).This failure had the potential for resident not having the right to appeal when necessary.Resident 24 was admitted on [DATE] with diagnoses including metabolic encephalopathy (brain dysfunction caused by underlying condition), anemia (when you have low levels of healthy red blood cells to carry oxygen throughout your body) and congestive heart failure (a chronic condition where the heart cannot pump blood efficiently, causing fluid buildup, fatigue, and shortness of breath).Review of facility document titled, Notice of Transfer or Discharge, dated 12/16/25, indicated, Resident 24 was discharged AMA on 12/16/25. There was no documentation that notice of discharge was sent to Ombudsman.During a concurrent interview and record review on 2/25/26 at 2:01 PM with Social Worker (SW), Resident 24's Notice of Transfer or Discharge dated 12/16/25 was reviewed. The notice indicated Resident 24 was discharged AMA on 12/16/25. According to the SW, Resident 24 left AMA as he wanted to go back home. SW said the notice was faxed to the Ombudsman. There was no documentation that notice of discharge was sent to Ombudsman. SW stated, I couldn't find it (proof of fax transmittal).

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 14) when the Yankauer suction tip (a bulb-tipped instrument used to remove saliva, blood, and mucus from the oral cavity to maintain a clear airway and prevent aspiration) was not covered while not in use.This deficient practice had the potential to transmit microorganisms and increase the risk of infection for Resident 14.Resident 14 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD - a long-term lung disease that makes it hard to breathe) and pulmonary fibrosis (lung disease that occurs when lung tissue becomes damaged and scarred).During an observation on 2/23/26 at 10:22 AM, Resident 14 was asleep in bed, oral suctioning equipment was at resident's bedside table. The canister contained light yellowish secretions. The Yankauer suction tip was not covered.During a concurrent observation and interview on 2/25/26 at 9:34 AM with Registered Nurse (RN) 2 in Resident 14's room, Resident 14 had oral suctioning equipment at bedside with the Yankauer suction tip not covered. RN 2 stated, The tip is not covered. It should be covered. RN 2 further stated that it was a hygiene issue because the suction tip goes to the mouth, as well as infection control and patient care issues.During a concurrent observation and interview on 2/25/26 aty 10:37 AM with Infection Preventionist (IP) in Resident 14's room, Resident 14 had oral suctioning equipment at bedside with the Yankauer suction tip not covered. IP stated, The tip should not be showing, should be covered to prevent contamination. It should be changed because it's potentially contaminated.Review of facility provided Instructions for Use for Covered Yankauer with Suction Handle indicated, .Put sleeve over Yankauer tip to cover.

Based on observation, interview, and record review facility staff failed to ensure a pharmacy printed label for a medication was legible. This failure had the potential for medication error. Findings: During a concurrent observation and interview on 2/23/26 at 11:19 AM with Registered Nurse (RN 1), the following was observed in medication cart 2. There was a bottle of nystatin powder (used to treat skin fungal and/or rashes) with an illegible pharmacy printed label. RN1 inspected the label, agreed the label exhibited water damage/ spreading of the ink and confirmed she could not read the resident's name on the label. RN1 stated staff should have called pharmacy and requested a new label for the nystatin powder. During an interview on 2/24/26 at 11:02 AM the Associate Director, Integrated Pharmacy Services (ADIPS) stated she expected staff to call pharmacy to print out a new label if a label becomes illegible. The ADIPS stated as a result of the above findings, staff did an audit and found and replaced another illegible medication label. Review of the facility's policy titled MEDICATION STORAGE POLICY - Skilled Nursing Facility Unit (SNF D/P), approved on 12/2025, indicated To ensure all medications in the Skilled Nursing Facility (SNF) are stored securely, properly labeled.

Based on observation, interview, and record review facility staff failed to accurately measure a controlled drug to enable exact reconciliations. Certain medications/chemical substances are subject to strict government control/oversight due to their potential for misuse and harm. For example: Morphine to treat moderate to severe pain.Staff failed to accurately measure the amount of Morphine within a bottle upon receipt and during shift-to-shift verification. This failure had the potential for drug diversion and medication error. Findings: During a concurrent observation, interview, and record review with Registered Nurse (RN 1) on 2/23/26 at 11:03 AM, a bottle of morphine was in the locked controlled substance cabinet of medication cart 3. Observation of the amount of morphine within the bottle indicated it was above the 30 ml (millimeter = a unit of liquid measurement) mark. This observation was confirmed with RN 1 and she agreed there was more than 30 ml of morphine inside the bottle. However, review of a facility document titled Controlled Drug Record, dated 11/20/2025, indicated 30 ml of morphine was initially delivered to the facility and on 2/23/2026, staff documented there should be 29.875 ml remaining. RN 1 attempted to explain why the current observed amount of morphine did not match what was recorded. RN 1 stated pharmacy sometimes overfill liquid medication, and this overfill was not accounted for in their documentation. RN 1 confirmed currently, the amount morphine in the bottle does not match what was documented in their shift-to-shift reconciliation document. RN 1 was asked why staff did not accurately document the overfill upon receipt. RN 1 offered no explanation. During an interview on 2/24/26 at 11:02 AM the Associate Director, Integrated Pharmacy Services (ADIPS) stated she was aware of the over fill issue and had discussed the issue with her team, but they have not implemented any way for staff to accurately account for the over fill. The ADIPS stated she was not aware of any pharmacy policies addressing the overfill issue. The facility was asked to provide their pharmacy policies regarding this overfill issue. Review of the facility's pharmacy policies provided below found no language addressing this overfill issue:Titled MEDICATION ADMINISTRATION POLICY- Skilled Nursing Facility (SNF) Unit, approved on 8/2025.Titled MEDICATION STORAGE POLICY - Skilled Nursing Facility Unit (SNF D/P), approved on 12/2025.

Based on observation, interview, and record review, the facility failed to obtain a physician's (MD) order and develop a comprehensive care plan for the use of external catheter for one of one sampled resident (Resident 26).These deficient practices had the potential for resident not to receive appropriate treatment and services.Resident 26 was admitted on [DATE] with diagnoses including sepsis (a life-threatening emergency caused by the body's extreme, harmful response to infection, often leading to rapid organ failure and death), hypertension (high blood pressure), and malnutrition.During an observation on 2/23/26 at 10:56 AM, Resident 26 was asleep in bed, with a catheter (a flexible tube used to deliver fluids into or withdraw fluids from the body) draining with yellowish urine to a drainage bag.During a concurrent interview and record review on 2/26/26 at 9:58 AM, with Licensed Vocational Nurse (LVN) 1, Resident 26's orders and care plans were reviewed. LVN 1 said Resident 26 had the catheter the on admission to help keep the skin dry and prevent skin breakdown. LVN 1 said they ask the MD for an order for the use of catheter, and stated, Yes, we ask the MD. LVN 1 confirmed there was no order for the use of external catheter for Resident 26 and stated, Should have an order for it. I don't see it. Additionally, LVN 1 acknowledged there was no care plan for the use of external catheter and stated, I don't see it. Furthermore, LVN 1 stated the importance of the care plan was to know what the interventions are to take care of the resident with external catheter.The facility was unable to provide a policy and procedure for the use of external male catheter. The facility provided a policy and procedure for the use of external female catheter. On 3/26/26 at 3:32 PM, the [NAME] President for Quality, Medical Staff and Compliance (VPQ) confirmed that the policy and procedure for external female catheter was used for external male catheter as well.Review of facility's policy and procedure (P&P) titled, External Female Catheter, dated 8/24, the P&P indicated, .Procedure: 1. Obtain a physician's order.

Based on interview and record review, the facility failed to report three allegations of abuse within the mandated time frame to California Department of Public Health (CDPH), the Ombudsman (advocates for residents in nursing homes), and local law enforcement for one of one sampled resident (Resident 34). In addition, the facility failed to report the result of its investigation to CDPH within five working days.This failure to follow mandated reporting timeframes had the potential to delay investigation and implementation of protective measures for all residents of the facility.Review of three facility documents, titled Report of Suspected Dependent Adult/Elder Abuse (Reports 1, 2, and 3), dated 12/21/24 indicated on Report 1 and Report 2 that on 12/20/24 (time not specified), Resident 34 reported to Social Services Manager (SSM) that Registered Nurse (RN) 3 physically and verbally abused him by intimidating him, dragging him from bed, giving his medications late, shoving laxatives in his mouth, and along with Hospital Aide (HA) 4, hosing him down in the shower and putting soap in his eyes. Report 3 dated 12/21/24 indicated Resident 34 reported to SSM that Licensed Vocational Nurse (LVN) 2 withheld his medications and made him suffer. Report 3 did not indicate the date and time the allegation was reported. Further review of Report 3 indicated LVN 2 was placed on leave effective 12/20/24 until further notice. Review of Resident 34's face sheet indicated Resident 34 was admitted on [DATE] with diagnoses that included Parkinsonism (refers to brain conditions that cause slowed movements, rigidity (stiffness) and tremors) and dementia (a progressive state of decline in mental abilities). Resident 34 was discharged on 5/23/25. During an interview on 2/26/26 at 11:33 AM with the Director of Quality, Patient Safety and Risk (DQSR) and SSM, SSM stated that on 12/20/25 before 5:00 PM, Resident 34 alleged he was being abused physically and mentally by RN 3, HA 4, and LVN 2. SSM stated she reported Resident 34's allegation of abuse to CDPH, the Ombudsman, and local police on 12/21/24. Review of the fax transmittal report for Reports 1, 2, and 3 indicated the facility notified CDPH, the Ombudsman, and local law enforcement on 12/21/24 at 3:00 PM (22 hours after the allegation was made). The DSQR stated that when staff are involved in an abuse allegation, it is the Human Resources Office (HRO - a department of a company in charge of issues related to employees) who conducts the investigation. During an interview on 2/26/26 at 1:08 PM the Director of Staff Development (DSD) stated the facility reports to 911 or non-emergency number immediately but not later than two hours if the abuse allegation includes physical harm or serious bodily injury. The DSD stated further, Other forms of abuse (financial, etcetera) are reported to CDPH and other appropriate agencies within 24 hours. During a telephone interview on 2/26/26 at 1:39 PM with the Chief Human Resources Officer (CHRO) and in-person interview with the Chief Nursing Officer (CNO), the CHRO stated that on 12/20/24, the HRO received a report that a resident made an allegation of harassment or abuse through SSM. The CHRO stated investigation started the following day and concluded on 1/10/25. When asked if the result of the investigation was reported to CDPH, the CHRO stated, Our department does not report to external agencies. The CNO stated that reporting to CDPH is not an HR function. During an interview on 2/26/26 at 2:12 PM, the CNO confirmed the result of investigation was not report to CDPH. Review of the facility's policy and procedures (P&P), titled D/P (distinct part) SNF (skilled nursing facility) Free of Elderly Abuse Policy, last revised and approved on 2/20205, indicated Purpose: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Further review of the P&P indicated Policy: The D/P SNF policies and procedures in accordance to federal and state regulations.I. Abuse Prohibited.D/P SNF shall abide by all abuse reporting laws that apply to skilled nursing facilities (SNFs) .VIII. Reporting Under Various Laws - All employees and certain contractors must follow the standards of conduct in this Policy to comply with the reporting requirements contained in various State and federal laws.A. Various Laws Requiring Reporting. D/P SNF is subject to certain basic reporting duties under . 2. The Federal Medicare/Medicaid (government-provided health insurance programs) laws .C. Reporting Duties Specific to Skilled Nursing.2. Under Federal laws, Medicare-participating SNFs must report immediately to DHS (referring to Department of Health and Human Services) all alleged resident mistreatment, neglect, or abuse. Review of the Appendix H of the P&P indicated Elder Abuse Reporting/Response Quick Guide.Timeframes to Report - Abuse and instances of 'serious bodily injury' must be reported immediately, but not later than two (2) hours. Parties to notify.California Department of Public Health.San Francisco Police Department.Ombudsman. The P&P did not include reporting of the results of all investigations of abuse allegation to the State Survey Agency (CDPH), within 5 (five) working days of the incident.

Based on observation, interview, and facility document review, the facility failed to have a system in place to ensure the safe storage of residents' personal perishable food. This failure had the potential to result in foodborne illness for 18 residents who took food by mouth out of a facility census of 19. Findings: Review of the Policy and Procedure (P&P) titled Bringing In Outside Food for Residents in Skilled Nursing Unit revised January 2024, showed Resident's nurse will store the perishable food in the resident refrigerator and freezer located in Dining Room on the SNF (Skilled Nursing Facility). The temperature will be systematically monitored, and a temperature log will be maintained in collaboration with the Facilities department. Review of the P&P titled Food Handling revised March 2024, showed temperatures of refrigerators and freezers will be monitored daily and documented. Refrigerators should be below 40 degrees Fahrenheit (F) and freezers at or below 0 degrees F. An observation on 8/5/24 at 12:10 p.m., showed a compact refrigerator and a compact freezer located in the resident dining room. The freezer was very full of unopened resident food. The freezer had a layer of ice build-up on the inside walls and ceiling. There was also ice build-up on the freezer door. Located on top of the freezer was untitled print-out of a calendar page dated July 2024. By each date, from June 30 to July 31, there was an initial and a checkmark. During a consecutive interview with Licensed Vocational Nurse (LVN) 1 and the Interim Director of Nursing (IDON) on 8/5/24 at 12:15 p.m., LVN 1 stated nursing was responsible for checking the freezer to ensure resident's frozen food was not stored over three days. LVN 1 confirmed the untitled calendar page with initials and checkmarks was documentation for checking the freezer. LVN 1 also confirmed there was no documentation for August 2024. IDON stated it was the P.M. (night) staff who monitored the freezer and were initialing the calendar page, and she did not know the meaning of the checkmarks but would follow-up. During an interview on 8/6/24 at 10 a.m., IDON stated the nursing staff were only checking for expiration dates on food for the food stored in the resident refrigerator. During an interview on 8/6/24 at 10:04 a.m., the Food and Nutrition Services Manager (FNSM) stated Food and Nutrition Staff did not have oversight of the resident refrigerator and freezer in the resident dining room. FNSM also said the resident refrigerator and freezer temperatures were not monitored by Facilities. FNSM stated if a frozen food package was not opened, it did not need to be discarded within three days, and the manufacturer's use-by/expiration date could be followed. FNSM stated she did not provide training to nursing staff regarding monitoring the resident food refrigerator/freezer. During an interview on 8/6/24 at 10:22 a.m., the Director of Staff Development (DSD) stated temperatures of the resident refrigerator and freezer should be recorded daily but she did not know what the appropriate refrigerator and freezer temperatures. DSD stated she did not have training regarding appropriate monitoring of the refrigerator and freezer. The DSD also stated she was not aware maintenance needs such as ice build-up was reported by nursing to Facilities.

Based on observation, interview, and record review, the facility failed to obtain a physician's (MD) order and develop a comprehensive care plan for the use of female external catheter for two of two sampled residents (Residents 158 and 201). This failure had the potential for residents to not receive appropriate treatment and services. Findings: 1. Resident 158 was admitted on [DATE] with diagnoses including obesity, chronic pain, adult failure to thrive (inability to sustain weight due to poor nutrition), and major depressive disorder. During an observation on 8/5/24 at 10:39 AM, Resident 158 was asleep in bed, with a catheter (a flexible tube used to deliver fluids into or withdraw fluids from the body) draining with yellowish urine to a canister and attached to a wall-mounted suction machine. During an interview on 8/5/24 at 12:38 PM, Resident 158 acknowledged the use of a catheter and stated, The catheter drains my urine. During a concurrent interview and record review on 8/7/24 at 10:15 AM, with Registered Nurse (RN) 3, Resident 158's orders and care plans were reviewed. RN 3 said that Resident 158 was urinary incontinent (loss of urine control), and she had a catheter to prevent skin breakdown, and stated, It's a Purewick catheter. RN 3 said that they ask the MD for an order for the use of the catheter, and stated, Yes, we ask the MD. RN 3 confirmed that there was no MD order for the use of Purewick catheter for Resident 158, and stated, No order. 43913 2. Resident 201 was admitted on [DATE] with diagnoses including pressure ulcer of sacral region stage 4, (bedsore on the tailbone area) hemiplegia (weakness of left side), and chronic respiratory failure with hypoxia (a body part is deprived of oxygen). During an observation on 8/5/24 at 10:00 AM, Resident 201 was in bed with a tubing connected to a canister to a suction machine. Canister had yellowish liquid inside. During an interview on 8/5/24 at 10:20 AM, with Licensed Vocational Nurse (LVN)2 and Interim Director of Nursing (IDON), LVN 2 said that it is a pad for incontinence of urine, so the pressure ulcer will not be wet from urine. The IDON confirmed it was a Purewick. During a concurrent interview and record review on 8/7/24 at 1:30 PM, with RN 1, Resident 201's orders and care plans were reviewed. RN 1 acknowledged there was no MD order for the use of external catheter and the care plan did not indicate the use of female external catheter for incontinence. RN 1 stated, That should be in the care plan, there is incontinence care plan, but no use of Purwick found in the care plan. The facility was unable to provide a policy and procedure for the use of female external catheter. The facility provided the Manufacturers Guide for Versette external catheter best practice guide.

Based on observation, interview, and record review, the facility failed to obtain a physician's (MD) order and develop a comprehensive care plan for oral suctioning for two of two sampled residents (Residents 151 and 205). This failure had the potential for residents to not receive appropriate treatment and services. Findings: 1. Resident 151 was admitted on [DATE] with diagnoses including transient ischemic attack (TIA-a brief episode when blood flow to the brain is temporarily cut off), dysphagia (difficulty swallowing), and depression. Mental status assessment indicated Resident 151 was moderately impaired. During an observation on 8/5/24 at 9:58 AM, Resident 151 was asleep in bed, oral suctioning equipment was at resident's bedside table. The canister was filled with light yellowish secretions. During an interview on 8/5/24 at 10:07 AM, Registered Nurse (RN) 2 said that the oral suction equipment was used as needed to suction secretions of Resident 151. Review of Resident 151's clinical record, the Order Summary Report (OSR), active orders as of 8/8/24, the OSR did not indicate an order for oral suctioning. Review of Resident 151's care plans indicated no care plan was developed for suctioning of oral secretions. 43913 2. Resident was admitted on [DATE], with diagnoses including encephalopathy (a disturbance in the brain function causing confusion, memory loss), and dysphagia. During an observation on 8/5/24 at 11:00 AM, Resident 205, was in bed, had a tubing attached to a suction catheter, and a canister filled with whitish fluid connected to the suction machine. During an interview on 8/5/24 at 11:15 AM, with LVN 1, LVN 1 confirmed Resident 205 required suctioning on as needed (PRN) basis and stated, I did not suction him yet on my shift. During an interview on 8/7/24 at 10:20 AM, with RN 2, per RN2 suctioning is on PRN basis, the canister and suction tip should be changed every 2-3 days, will check the policy, date is important to know when to change the set. Review of Resident 205's clinical records, the OSR, there was no MD order for suctioning. Review of Resident 205's care plans indicated no care plan for suctioning of oral secretions. During a concurrent interview and record review on 8/7/24 at 2:00 PM, with RN 1, Residents 151 and 205's orders and care plans were reviewed. RN1 acknowledged that there was no MD order and no care plan found in the clinical records for oral suctioning.

Based on observation, interview, and record review, the facility failed to ensure residents were assessed for risk of entrapment, risk and benefits for the use of bed rails were reviewed and bed rail assessment reflect the use of bed rails for three of eight sampled residents (Residents 151, 159, and 207). These deficient practices had the potential to put the residents at risk for entrapment, accidents, or injuries due to the use of bed rails. Findings: 1. Resident 151 was admitted on [DATE] with diagnoses including transient ischemic attack (TIA-a brief episode when blood flow to the brain is temporarily cut off), prostate cancer, and depression. Mental status assessment indicated Resident 151 was moderately impaired. During an observation on 8/5/24 at 9:58 AM, Resident 151 was asleep in bed, with both upper bed rails up. During a subsequent observation on 8/7/24 at 9:54 AM, Resident 151 was asleep in bed, with both upper bed rails up. On concurrent interview with Hospital Aide (HA) 1, HA 1 said that Resident 151 grabs the bed rails when turning, and stated, It is used for mobility. Review of Resident 151's clinical record, the Bed Rail Assessment (BRA) with effective date of 3/27/24, indicated, .Side Rails/Assist Bar are not indicated at this time . The BRA did not indicate Resident 151 was assessed for risk of entrapment and risks and benefits of bed rails were not reviewed with the resident. There was no care plan for the use of bed rails. 2. Resident 159 was admitted on [DATE] with diagnoses including hypertension (high blood pressure), heart failure (condition in which the heart doesn't pump blood as well as it should), intracerebral hemorrhage (a type of stroke caused by bleeding within the brain tissue itself), and muscle weakness. During an observation on 8/5/24 at 10:47 AM, Resident 159 was in bed, pleasant, alert, and oriented. Resident 159's both bed rails were up and grabbed it to turn to her side. During an interview on 8/7/24 at 10:00 AM, Registered Nurse (RN) 3 said that Resident 159 had right side weakness. RN 3 confirmed that Resident 159 had both bed rails up and was used for movement. RN 3 stated, It is used as an enabler, for mobility. Review of Resident 159's clinical record, the BRA with effective date of 7/19/24, indicated, Resident 159 expressed a desire to have side rails/assist bar for safety and/or comfort and side rails/assist bar are not indicated at this time. The BRA did not indicate Resident 159 was assessed for risk of entrapment and risks and benefits of bed rails were not reviewed with the resident. There was no care plan for the use of bed rails. 43913 3. Resident 207 was admitted on [DATE], with diagnoses including bacterial infection, enterocolitis due to Clostridium Difficile (a highly contagious bacterial infection of the colon), and osteoarthritis of knees (knees hurting, stiff or swollen due to knee cartilages broken down). During a concurrent observation and interview on 8/5/24 at 11:30 AM, with Licensed Vocational Nurse (LVN) 2, Resident 207 was in bed, awake, alert, and oriented, on tube feeding. Both bed rails were up, and resident was able to reach and hold on to it. Resident 207 said he has been in the facility for several months now, and stays in bed most of the time. LVN 2 confirmed Resident 207 has both bed rails up to help him reposition in bed. Resident 207 stated, I like this, when touching the bed rails to position himself. Resident 207 did not know if he was asked about the use of bed rails. During a concurrent interview and record review on 8/7/24 at 1:30 PM, with RN1, Resident 207's orders and care plans were reviewed. RN 1 confirmed that there was no physician's order and care plan for the use of bed rails. Review of Resident 207's BRA with effective date of 2/13/24, consent for the use of bed rails was done on 2/13/24. The BRA indicated, .Siderails/Assist bar are not indicated at this time . During an interview on 8/6/24 at 2:00 PM, with the Interim Director of Nursing (IDON), IDON said that bed rails need physician's order, assessment, consent, and care plan. Review of facility Policy and Procedure, Restraint Reduction Program, with approval date of 9/2023, indicated, .Policy: The least restrictive alternative measures will be used according to the resident's assessment and care plan .

Based on observation, interview, and record review the facility failed to ensure safe medication storage practice in one of three medication carts (Med Cart, a locked mobile cart used to store medications and supplies) when several prescription medications were kept on top of a med cart and available for taking. This failed practice could contribute to unsafe medication storage and the potential for drug diversion. Findings: During a concurrent observation and interview on 8/6/24 at 8:33 AM, with Interim Director of Nursing (IDON), a medication cart was found on the hallway outside of a Resident's room (room [ROOM NUMBER]). On top of the med cart were bottles of prescription medications (metoprolol 50 mg - medication for treatment of high blood pressure, oxcarbazepine 300 mg - a medication used in the treatment of partial seizures, lisinopril 40 mg - medication for treatment of high blood pressure, and tamsulosin 0.4 mg - medication used in reducing the symptoms of an enlarged prostate gland) belonging to Resident 202. These medications were left there unattended on the hallway while the Licensed Vocational Nurse (LVN 2) stayed in a Resident room. During a concurrent interview with the IDON on 8/6/2024 at 8:33 AM, she confirmed the medications should not be left unattended on the med cart when LVN 2 left to provide nursing care to a Resident. Review of the facility's policy titled Drug Storage, dated April 2023, indicated All drugs are stored in designated area in SNF medication carts or lockable cabinets .

Based on observation, interview and record review, the facility failed to develop a comprehensive care plan (CP) that included measurable objectives and specific interventions for one of eight sampled residents (Residents 159) when there was no individualized person-centered CP for the use of Venlafaxine (medication used to treat depression) for Resident 159. This failure had the potential for not meeting the resident's nursing needs and goals to attain their highest practicable well-being. Findings: Resident 159 was admitted on [DATE] with diagnoses including hypertension (high blood pressure), cocaine abuse, and depression. Review of Resident 159's Order Summary Report, active orders as of 8/8/24, indicated, Resident 159 had an order of Venlafaxine with a start date of 7/19/24. During a concurrent interview and record review on 8/7/24 at 10:39 AM, with Registered Nurse (RN) 3, Resident 159's care plans were reviewed. RN 3 confirmed that Resident 159 had an order for Venlafaxine with a start date of 7/19/24. RN 3 acknowledged that there was no care plan for Resident 159's antidepressant medication, and stated, There should be a plan of care. There's none. Review of facility policy titled, Resident Assessment with approval date of 9/23, indicated, .(d) Use. A facility maintains all resident assessments completed within the previous 15 months in the resident's active record and use the results of the assessments to develop, review, and revise the resident's comprehensive plan of care .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of two sampled residents (Resident 151) when the tip of the oral suction (involves inserting a small plastic tube attached to a suction machine into the mouth to remove saliva or mucus) tubing was touching the floor. This deficient practice had the potential to transmit microorganisms and increase the risk of infection for Resident 151. Findings: Resident 151 was admitted on [DATE] with diagnoses including transient ischemic attack (TIA-a brief episode when blood flow to the brain is temporarily cut off), dysphagia (difficulty swallowing), and depression. Mental status assessment indicated Resident 151 was moderately impaired. During an observation on 8/5/24 at 9:58 AM, Resident 151 was asleep in bed, oral suctioning equipment was at resident's bedside table. The canister was filled with light yellowish secretions. The tip of the suction tubing was touching the floor. During an interview on 8/5/24 at 10:07 AM, Registered Nurse (RN) 2 said that the oral suction equipment was used as needed to suction secretions of Resident 151. RN 2 acknowledged that the tip of the suction tubing was touching the floor, and stated, It should not be touching the floor. It's considered contaminated. That's for infection control. During an interview on 8/7/24 at 10:30 AM, with the Interim Director of Nursing (IDON), the IDON said the tip of the suction tubing should not be touching the floor to prevent cross contamination. The IDON stated, For infection control and safety, and best practice. During an interview on 8/8/24 at 2:30 PM, with the Infection Preventionist (IP), the IP said that the suction tubing is attached to a Yankuer catheter (small plastic tube). The IP acknowledged that the suction tubing was touching the floor, and stated, That is contaminated because it's touching the floor. It may cause spread of infection. Review of facility policy titled, Cleaning and Disinfection/Non-critical care and shared equipment, last revised on 3/2024, indicated, Policy: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread on infection in accordance with State and Federal Regulations, and national guidelines. The policy did not indicate care for oral suction equipment.

Based on interview and record review, the facility failed to ensure two of four sampled residents (Residents 158 and 159) were free from unnecessary psychotropic medication (drug that affect brain activities associated with mental processes and behavior) when there was no specific target behavior monitoring for the use of Venlafaxine (medication used to treat depression). This failure had the potential for residents to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the residents' mental, physical, and psychosocial well-being. Findings: 1. Resident 158 was admitted on [DATE] with diagnoses including obesity, chronic pain, adult failure to thrive (inability to sustain weight due to poor nutrition), and major depressive disorder. During a review of Resident 158's clinical record, the Order Summary Report (OSR), active orders as of 8/8/24, indicated, .Venlafaxine HCl ER Oral Tablet Extended Release 24-hour 75 milligram (mg) Give 1 tablet by mouth one time a day related to major depressive disorder .Start Date 5/21/24 . During a review of Resident 158's clinical record, the Medication Administration Record (MAR), dated 7/1/24 to 7/31/24 indicated, .Venlafaxine HCl ER Oral Tablet Extended Release 24-hour 75 mg Give 1 tablet by mouth one time a day related to major depressive disorder . was administered daily at 9:00AM from 7/1/24 to 7/31/24. During a review of Resident 158's clinical record, the MAR dated 8/1/24 to 8/31/24 indicated, .Venlafaxine HCl . was administered daily at 9:00 AM from 8/1/24 to 8/7/24. During a concurrent interview and record review on 8/7/24 at 10:15 AM with Registered Nurse (RN) 3, Resident 158's OSR and MAR were reviewed. RN 3 confirmed that Resident 158 had a diagnosis of depression and acknowledged that the clinical records did not indicate the specific target behavior symptom to be monitored for depression and the use of Venlafaxine, and stated, No behavior monitoring for depression. None. 2. Resident 159 was admitted on [DATE] with diagnoses including hypertension (high blood pressure), cocaine abuse, heart failure (condition in which the heart doesn't pump blood as well as it should), and depression. During a review of Resident 159's clinical record, the OSR, active orders as of 8/8/24, indicated, .Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 mg Give 75 mg by mouth at bedtime for depression .Start Date 7/19/24 . During a review of Resident 159's clinical record, the MAR dated 7/1/24 to 7/31/24 indicated, .Venlafaxine HCl ER Oral Capsule Extended Release 24 Hour 75 mg Give 75 mg by mouth at bedtime for depression . was administered at 9:00 PM from 7/19/24 to 7/31/24. During a review of Resident 159's clinical record, the MAR indicated, .Venlafaxine HCl . was administered at 9:00 PM from 8/1/24 to 8/6/24. During a concurrent interview and record review on 8/7/24 at 10:39 AM with RN 3, Resident 159's OSR and MAR were reviewed. RN 3 confirmed that Resident 159 had a diagnosis of depression and acknowledged that the clinical records did not indicate the specific target behavior symptom to be monitored for depression and the use of Venlafaxine, and stated, No behavior monitoring for the use of antidepressant. None. During an interview on 8/7/24 at 1:22 PM, with the Pharmacist (PHM), for psychotropic medications, PHM confirmed that there was no specific target behavior monitoring for the use of Venlafaxine for Residents 158 and 159. PHM acknowledged that behavior monitoring is performed to check if the use of medication is effective. During an interview on 8/8/24 at 10:23 AM, with the Interim Director of Nursing (IDON), for psychotropic medications specific target behavior monitoring, the IDON said that monitoring is done to see if medication is effective, or dose needs to be changed. IDON further stated that behavior monitoring is done every shift. Review of facility policy titled, Drug Regimen Review/Pharmaceutical Care Monitoring - SNF last reviewed on 3/2024, indicated, .Upon conducting the DRR, the pharmacist may identify and report irregularities in one or more of the following categories .f. The use of a medication without evidence of adequate monitoring .

Based on observation, interviews and record review, the facility did not provide daily, the nurse staffing information, when on 8/5/24, 8/6/24, and 8/7/24, there was no staffing data information posted. Findings: During an interview on 8/5/24 at 10:22 AM, with Interim Director of Nursing (IDON), per IDON, the staffing information should be posted. Facility provided daily nursing assignments and monthly staff schedule. Not the staffing data required. On 8/7/24, asking the IDON for the staffing posting, the Census and Direct Care service Hours Per Patient Day (DHPPD) was posted in the nursing station. Review of facility policy and procedure titled, Posted Nurse Staffing Information, dated 4/20/23, indicated, .It is the policy of the facility to make staffing information readily available in a readable format to residents and visitors at any given time .1. The facility will post the following on a daily basis . 2. The facility will post the nurse staffing data daily at the beginning of each shift.

Based on interview and record review, the facility did not send a copy of the reason for discharge to the office of the local Ombudsman, when one of two residents (Resident 2) was discharged to a lower level of care (board and care home). Findings: Review of Physician Discharge Summary, dated 6/28/24, indicated, .Resident 2 was admitted [DATE] with diagnoses including atrial fibrillation (irregular heartbeat), obesity, was involved in minor MVA (Motor Vehicle Accident) . Patient completed therapy .patient is stable to discharge with home care . During an interview on 8/8/24 at 11:35 AM, with Social Work Manager (SWM), SWM, when patient was admitted , APS (Adult protective Services) was already on the case. Patient was referred to (IOA) Institute on Aging, who helped SW apply for assisted living waiver, so she can go to a board and care. The board and care were able to accept her as Hoyer-lift and ADLs (Activities of daily living) assisted patient. Referred patient to Upward Health for case management if she will need to. This is a facility-initiated discharge. During a concurrent interview and record review on 08/08/24 02:57 PM, with SMW, no notification of Ombudsman in writing was found in the clinical records. SWM said, they were not aware that Ombudsman will have to be notified of discharges. Review of facility policy and procedure titled, Transfer and Discharge Requirements, dated 4/13/23, indicated, .Policy: The D/P SNF Transfer and Discharge Requirements policies and procedures in accordance to federal and state regulations . The policy did not indicate notice to Ombudsman on all discharges, according to federal regulations.