Every finding on record at Palo Alto Post-Acute

Based on observation, interview and record review, the facility failed to ensure palatability and temperature of the foods served were maintained when: 1. The pureed (a smooth, thick liquid or paste made by crushing or grinding solid foods using a blender or food processor) fish and pureed bread tasted bland (lacking taste or flavor); and 2. The temperature of the hot foods served were below the desired level. These failures could lead to decreased nutrient intake for the 55 facility residents receiving food from the kitchen. Findings: 1. During the test tray observation and tasting with the dietary manager (DM), on 5/28/25 at 12:45 p.m. to 12:52 p.m., two test plates in the trays were brought and tasted. One of the test plates contained regular (no modification or restriction) fish, regular vegetables and regular orzo (type of short-cut pasta that is shaped like a large grain of rice). The second test plate contained pureed fish, pureed bread, pureed vegetables and pureed orzo (pasta). Tasted the pureed foods after and the pureed fish and pureed bread had no taste or tasted bland. During an interview with the DM after he tasted the test plate with pureed foods, on 5/28/25 at 12:53 p.m., the DM acknowledged that the pureed fish and pureed bread, tasted bland. The DM further acknowledged that he would follow up on this concern and on improving the taste of these pureed foods. During an interview with the registered dietitian (RD), on 5/29/25 at 2:35 p.m., the RD verified that the foods to be served to the residents should be palatable and not bland in taste. The RD further verified that he would check on this concern. Review of the facility's policy titled, Food and Dining Services Policies and Procedures: Resident Food Preferences, effective 11/2016 indicated, Satisfy resident's tastes and appetites by determining their food preferences at meals . Review of the facility's policy titled, Food and Dining Services Policies and Procedures: Recipes, effective 2/2009 indicated, Ensure consistent food and dining quality . Review of the facility's policy and procedure titled, Food and Dining Services Policies and Procedures: Resident Food Acceptability, effective 2/2009 indicated, Resident's acceptance of the menu and food is monitored routinely. All food and dining services staff and nursing staff are responsible for monitoring resident meal satisfaction . 2. During the test tray observation and tasting with the DM, on 5/28/25 at 12:45 p.m., the DM checked the temperatures of the foods in the two test plates in the trays that were brought, before they were tasted. The temperatures of the following hot foods were below 135 degrees Fahrenheit (F, temperature scale), which was the required temperature of the hot foods to be served in the facility: a. regular fish - 134 degrees F; b. regular vegetable - 125 degrees F; c. puréed fish - 122 degrees F; d. puréed orzo - 117 degrees F and e. puréed bread - 114 degrees F. During an interview with the DM on 5/29/25 at 4:35 p.m., the DM verified that the hot foods to be served to the residents should be 135 degrees F or above and temperatures of the regular fish, regular vegetables, pureed fish, pureed orzo and pureed bread were below 135 degrees F and would follow up on this concern. During an interview with the RD on 5/29/25 at 5:03 p.m., the RD verified that hot foods served to residents should be 135 degrees F or above and would check on that issue. Review of the facility's policy and procedures titled, Food and Dining Services Policies and Procedures: Safe Food Temperatures, effective 2/2009 indicated, Food temperatures are maintained at acceptable levels during food storage, preparation, holding, service, delivery Hot foods will be held at 135 degrees F or higher during meal service (on the tray line) .

Based on observation, interview, and record review, the facility failed to ensure, cooking and kitchen equipment were maintained properly and foods in the kitchen were prepared in accordance with professional standards for food safety when: 1. There were unsanitary cooking and kitchen equipment stored in the kitchen and, 2. Kitchen staff did not perform hand hygiene and sanitation during the tray line preparation. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness (illness resulting from contaminated food) and cross-contaminated food for the 55 residents who received food from the facility kitchen. Findings: 1. During the initial kitchen tour observation with the dietary manager (DM), on 5/27/25 at 9:25 a.m., observed 5 large cooking pans with brownish to blackish discolorations and rusty spots in them. During an interview with the DM on 5/27/25 at 9:26 a.m., the DM acknowledged that the 5 large cooking pans had brownish to blackish discolorations and rusty spots and had them removed right away. He then stated that he would have them replaced. During an interview with the registered dietitian (RD), on 5/29/25 at 2:35 p.m., the RD verified that the 5 large cooking pans with brownish to blackish discolorations and rusty spots should not be kept there in the kitchen and should have been replaced. The RD then stated that he would follow-up on that concern. 2. During the tray line preparation observation on 5/28/25 at 12:10 p.m., dietary aide C (DA C) helped in filling out the liquids of the resident meal trays in the tray carts. Observed DA C, went out of the kitchen still wearing her gloves, then went back inside and proceeded to help right away with the tray line preparation without removing her used gloves, doing hand washing and putting on new gloves before going back to helping with the tray line preparation. During an interview with DA C on 5/28/25 at 2:35 p.m., DA C verified that she should have removed her gloves, washed her hands and put on new gloves, before she continued helping with the tray line preparation, when she went out of the kitchen and then came back right after. During an interview with the DM on 5/28/25 at 12:55 p.m., the DM verified that DA C should have removed her used gloves, should have done hand washing and should have put on new gloves after she went out of the kitchen and before helping back with the tray line preparation, when she came back. During an interview with the RD on 5/29/25 at 2:35 p.m., the RD verified the above concern. The RD stated that he would remind the kitchen staffs about proper hand hygiene and sanitation. Review of the facility's policy and procedure titled, Food and Dining Services Policies and Procedures: Personnel Sanitation Standards, effective 2/2009 indicated, Maintain sanitation among food and dining services personnel. Food and dining services personnel follow sanitary standards and practices . Hands must be washed after each trip to the restroom, after leaving storage rooms, washrooms, etcetera .

2a. Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE]. Review of Resident 53's physician order, dated 5/25/25, indicated she had an order for oxygen 2-3 liters per minute (LPM) as needed for shortness of breath. During an observation and interview with the infection preventionist (IP) on 5/27/25, at 10:46 a.m., the filter of Resident 53's oxygen concentrator was dusty. The IP confirmed the filter was dusty and stated the filter should be cleansed every week. 2b. Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 112's physician order, dated 5/22/25, indicated he had an order for oxygen 2-3 LPM continuous every shift. During an observation and interview with the IP on 5/27/25, at 10:51 a.m., the filter of Resident 112's oxygen concentrator was dusty. The IP confirmed the filter was dusty and stated the filter should be cleansed every week. Review of the facility's policy, Oxygen Concentrator, dated 12/3/24, indicated . 5. Care of the Concentrator: a. Follow manufacturer recommendations for the frequency of cleaning filters and servicing the device. f. Oxygen concentrators should have a preventive maintenance. 3. During an observation on 5/27/25, at 10:12 a.m., certified nursing assistant B (CNA B) put on gloves, picked up trash bag in Resident 12's room, walked out of the room to throw the trash bag in the hamper which was parked on the other side in the hallway with gloves on her hands. CNA B came back to Resident 12's room and prepared his bed with the same gloves on her hands. Resident 12 stated he needed mouth wash. CNA B removed her gloves but did not sanitize her hands, walked out of the room to get mouth wash from the supply room for the resident. During a concurrent interview with CNA B, she stated she should have the hamper at the resident's room door, so she did not have to walk out in the hallway to throw the trash. CNA B stated she should remove her gloves and sanitize her hands when walking out of the resident room and in the hallway. During an interview with the IP on 5/30/25, at 3:02 p.m., she stated staff should not walk out of resident room with gloves on and should sanitize their hands after removing the gloves. 4. During an observation on 5/28/25, at 12:28 p.m., certified nursing assistant A (CNA A) sanitized her hands, put on gloves, moved Resident 212's bed, pulled Resident 212 up, repositioned Resident 212 in bed, and raised Resident 212's head of bed up. CNA A removed her gloves and held the used gloves in her hand. Without sanitizing her hands, CNA A opened the straw and put it in Resident 212's glass of cranberry juice, removed the cover of the fruit cup, removed the lid of the lunch plate, picked up the spoon and pressed on the rice on the lunch plate with the spoon, then walked out of Resident 212's room and in the hallway to place the lid of the plate in the lunch cart without sanitizing her hands. During a concurrent interview with CNA A, she stated she should throw the gloves in the trash can, sanitize her hands before assisting the resident with meal and when walking out of the resident room. During an interview with the IP on 5/30/25, at 3:08 p.m., she stated staff should sanitize their hands before assisting the resident with meal and when walking out of the resident room. Review of the facility's policy, Personal Protective Equipment (PPE), dated 6/4/24, indicated . 4. Indications/considerations for PPE use: a. Gloves: . ii. Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. iv. Change gloves and perform hand hygiene between clean and dirty tasks, when moving from one body part to another, when heavily contaminated, or when torn. vii. Dispose of gloves in appropriate waste receptacle. Based on observation, interview, and record review, the facility failed to implement infection control measures when: 1. Licensed vocational nurse F (LVN F) did not do hand hygiene in between administration of medications for two residents (Resident 2 and Resident 8); 2. The filters of Resident 53's and Resident 112's oxygen concentrators were dusty; 3. Certified nursing assistant B (CNA B) walked out of Resident 12's room with gloves on and did not sanitize her hands after removing the gloves; and 4. Certified nursing assistant A (CNA A) did not sanitize her hands before assisting Resident 212 with meal and when walking out of the resident room. These failures had the potential to result in the transmission and spread of infection throughout the facility. Findings: 1. During a medication pass observation on 5/28/25 at 4:08 p.m. with Licensed Vocational Nurse (LVN) F, LVN F prepared and administered oral medications to Resident 2. LVN F used gloves and did not do hand hygiene before putting on and after removing gloves. LVN F did not do hand hygiene after administering medications to Resident 2. At 4:13 p.m., LVN F proceeded to prepare and administer oral medications to Resident 8. LVN F did not do hand hygiene prior to administration of medications for Resident 8. LVN F also used gloves for Resident 8 and did not do hand hygiene before wearing and after removing gloves. LVN F verified she did not do hand hygiene in between administration of medications for Resident 2 and Resident 8 and before wearing and after removing gloves. LVN F stated hand hygiene should have been done. During an interview on 5/29/25 at 3:44 p.m. with the Director of Nursing (DON), the DON stated, Hand hygiene must be done during medication pass in between residents. A review of facility's policy and procedure (P&P) entitled, Hand Hygiene revised 5/29/24, the P&P indicated, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table: Condition: Between resident contacts- Either soap and water or alcohol-based hand rub Before preparing or handling medications- Either soap and water or alcohol-based hand rub .6. Additional considerations: a. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves .

Based on interview and record review, the facility failed to ensure that facility staff monitored and documented the side effects of antibiotic (ATB, medication that fight bacteria) therapy for seven out of 11 residents (Residents 165, 9, 57, 267, 15, 269, and 212) who were receiving antibiotics. This failure had the potential to result in unrecognized adverse drug reactions or inappropriate antibiotic use. Findings: 1. A review of Resident 165's admission record indicated the resident was admitted on [DATE] with diagnoses that included Tuberculosis (TB, an infectitious disease cause by bacteria that primarily affects the lungs) of lung. A review of Resident 165's Order Summary Report indicated that on 5/11/25, the physician ordered the following antibiotics: Levofloxacin (antibiotic used to treat bacteria, including TB) 750 milligrams (mg,unit of measurement) 1 tablet to be given by mouth (PO) daily for pulmonary (lungs) tuberculosis, Ethambutal (antibiotic used to treat TB) 400 mg 3 tablets PO daily for right upper lung (RUL) cavitary lesion (an area of lung tissue damaged by infection) and Linezolid (antibiotic used to treat infection) 600 mg 1 tablet PO daily for RUL cavitary lesion. 2. A review of Resident 9's admission record showed admission on [DATE] with acute and chronic respiratory failure with hypoxia (a condition where the lungs cannot get enough oxygen into the blood), and pneumonia (a lung infection). A review of Resident 9's Order Summary Report indicated the physician ordered Vancomycin (antibiotic used to prevent or treat bacterial infection) 50 mg/ml, 2.5 ml PO daily for prophylaxis (a preventive measure). 3. A review of Resident 57 admission record indicated the resident was admitted on [DATE] with non-rheumatic aortic valve stenosis (a narrowing of the heart's aortic valve that is not caused by rheumatic fever). A review of Resident 57's Order Summary Report indicated the physician ordered Ciprofloxacin (antibiotic used to treat infection) 250 mg PO twice daily for UTI (infections of the bladder or urinary system). 4. A review of Resident 267's admission record indicated resident was admitted on [DATE] with osteomyelitis of the thoracic spine (a serious bone infection in the spine) and discitis in multiple spinal areas (inflammation of the discs between the bones of the spine). A review of Resident 267's Order Summary Report, dated 5/9/25 included Ceftriaxone (antibiotic used for serious infections like bone or spine infections) 2 grams (gm, unit of mass) IV (intravenous, administered into a vein) every 12 hours for discitis (infection in the intervertebral disc space). 5. A review Resident 15's admission record indicated resident was admitted on [DATE] with chronic obstructive pulmonary disease (COPD, a long-term lung disease that makes it hard to breathe.) A review of the facility's Antibiotic List dated 5/2025 showed that on 5/28/25, the physician ordered Cefdinir (an oral antibiotic used to treat respiratory tract infections, including pneumonia) 300 mg PO twice daily for pneumonia. 6. A review of Resident 269's admission record indicated resident was admitted on [DATE] with aftercare following a liver transplant (surgical procedure where a diseased or damaged liver is removed and replaced with a healthy liver from a donor) and cirrhosis of the liver (a condition where the liver is permanently scarred and cannot function well). A review of the facility's Antibiotic List, indicated that on 5/21/25, Resident 269 was prescribed Bactrim (antibiotic used to prevent bacterial infections) 400-80 mg via nasogastric (NG, means the medication is given through a tube from the nose to the stomach) every Mon, Wed, and Fri as prophylaxis for organ transplant. During an interview on 5/29/25 at 4:10 p.m., registered nurse (RN) G stated that nurses assess for rash, hives, dizziness, or other side effects during antibiotic therapy, and that documentation should be entered in the MAR (medication administration record) or progress notes. During a concurrent interview and record review with RN H , evening supervisor, on 5/29/25 at 4:15 p.m., RN H stated that facility staff check for allergic reactions, nausea, vomiting, or changes in cognition, and this should be documented. RN H confirmed no documentation was found for side effect monitoring for the residents listed above. During an interview with the Infection Preventionist (IP) on 5/29/25, at 4:33 p.m., the IP stated that nurses should monitor for side effects while residents are on antibiotics and document those findings. During an interview with the Director of Nursing (DON) on 5/29/25 at 4:40 p.m., the DON confirmed that there was no documentation of antibiotic monitoring in the MAR or progress notes for the above residents. The DON stated that monitoring for side effects should be documented in the progress notes. The DON further stated that she would educate nursing staff regarding proper documentation of antibiotic therapy monitoring. 7. During an observation of Resident 212 on 5/27/25 at 10:27 a.m., Resident 212 was laying in his bed, alert, calm, comfortable and verbally responsive. Review of Resident 212's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident) indicated, Resident 212 was admitted to the facility on [DATE]. Review of Resident 212's order summary report dated 5/29/25 indicated, Resident 212 had an order of Ciprofloxacin Hydrochloride (antibiotic used to treat bacterial infections) oral tablet, 500 milligrams (mg, unit of mass), give 1 tablet by mouth two times a day for urinary tract infection (UTI, an infection that occurs in any part of the urinary system or the system of organs that makes urine), for 7 days, started on 5/23/25. During a concurrent review of Resident 212's clinical records and interview with licensed vocational nurse D (LVN D), on 5/30/25 at 9:43 a.m., LVN D verified that Resident 212 did not have any progress notes (type of medical record used to document a patient's health status and treatment progress) for his use of Ciprofloxacin Hydrochloride antibiotic, since it was started on 5/23/25. During a concurrent review of Resident 212's clinical records and interview with the DON, on 5/30/25 at 1:10 p.m., the DON verified that Resident 212 was on Ciprofloxacin Hydrochloride antibiotic but there was no progress notes and no monitoring for the side effects of the antibiotic use. The DON further verified that she would follow up on this concern. Review of the facility's policy titled, Antibiotic Prescribing Practices, reviewed/revised on 5/29/24 indicated, Antibiotic use protocols, including prescribing practices, are implemented as part of the facility's Antibiotic Stewardship Program for the purpose of optimizing the treatment of infections and reducing adverse events associated with antibiotic use .Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness.

Based on observation, interview, and record review, the facility failed to treat one of 14 residents (8) with respect and dignity when certified nursing assistant A (CNA A) was standing and feeding Resident 8. This failure had the potential to cause feeling of low self-esteem for the resident. Findings: Review of Resident 8's admission Record indicated she was admitted to the facility on [DATE]. During an observation on 5/28/25, at 12:37 p.m., CNA A was standing and feeding lunch to Resident 8 in her room. During a concurrent interview with CNA A, she stated that she did not feel comfortable if she sat down and fed Resident 8, because she had to reach to Resident 8 to feed her. CNA A acknowledged that she could adjust the bed level and reposition Resident 8, so that she could reach to Resident 8 comfortably. CNA A stated she should sit down while feeding Resident 8. Review of the facility's policy, Promoting/Maintaining Resident Dignity During Mealtimes, dated 10/21/24, indicated . 5. All staff will be seated, if possible, while feeding a resident.

Based on observation, interview, and record review, the facility failed to protect resident's rights to confidentiality for one of 14 residents (112) when the infection preventionist (IP) left her laptop screen open with Resident 112's face sheet (a document summarizing key patient information, including name, address, date of birth , emergency contact, medical history, medications, allergies, and insurance details) open and unattended on top of the stand in the hallway. This failure had the potential to compromise the resident's privacy and confidentiality. Findings: Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE]. During an observation on 5/27/25, at 10:55 a.m., the IP was in the hallway. Her laptop was on the stand and in front of her. The laptop was open with Resident 112's face sheet displayed on the screen. The IP left her laptop there and walked to the lobby to talk with the maintenance director. Then, the IP walked farther, across the lobby, to the other hallway to talk with other staff. During an interview with the IP on 5/27/25, at 10:57 a.m., she confirmed that she left her laptop open with Resident 112's face sheet open and unattended in the hallway. The IP stated she should close her laptop before walking away to talk with other staff. Review of the facility's policy, Health Insurance Portability and Accountability Act (HIPAA, a federal law that sets a national standard to protect medical records and other personal health information) Security Measures, dated 5/12/25, indicated . 8. Physical safeguards will be implemented that limit physical access to its electronic information systems and the facility or facilities in which they are housed, while ensuring that properly authorized access is allowed.

Based on interview and record review, the facility failed to ensure two of 14 sampled residents (Resident 39 and Resident 22) were free from unnecessary psychotropic medication (medications that affect brain activities associated with mental processes and behaviors) use when: 1. Resident 39 was administered Belsomra (Suvorexant, a sedative hypnotic medication used to treat insomnia) without informed consent (a process where the resident or their representative is educated about the risks, benefits, and alternatives to a medication before agreeing to its use), monitoring for sleep or side-effects, and a care plan addressing the medication's use. 2. Resident 22 did not have an updated informed consent when antipsychotic medication, Perphenazine (used to treat the symptoms of schizophrenia, a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions) dose was increased. These failures put residents at risk for adverse effects of psychotropic medications. Findings: 1. A review of Resident 39's admission record indicated the resident was admitted to the facility on [DATE] with diagnoses that included: depression (a mental health condition that causes persistent sadness and loss of interest), and schizoaffective disorder (a chronic mental health condition that includes symptoms of hallucinations or delusions). A review of Resident 39's Order Summary Report indicated that on 5/19/25, the physician prescribed Belsomra 10 milligrams (mg, unit of measurement), to be given as one tablet by mouth at bedtime for insomnia (difficulty sleeping). A review of Resident 39's clinical records showed no documentation of informed consent before initiating Belsomra, sleep monitoring or monitoring for side-effects, or a care plan that included the use of Belsomra or interventions. During a concurrent interview and record review with the Director of Nursing (DON) on 5/30/25 at 10:30 a.m., the DON confirmed that there was no documented informed consent obtained before Belsomra was administered to Resident 39. There was no monitoring for sleep or side-effects recorded after the medication was started. The DON further stated that Resident 39's care plan addressed the problem of insomnia, but did not include specific interventions related to the use of Belsomra or monitoring its side-effects. Review of facility's policy titled Use of Psychotropic Medications, revised date 2/5/25, indicated: .9) Prior to initiating or increasing psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication .the facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline .14) The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluate on an ongoing basis, such as .d) In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care. 15) The resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record . 2. A review of Resident 22's clinical records indicated an initial admission date of 9/17/24 and diagnoses included, bipolar disorder, unspecified (a mental health condition where a person experiences extreme shifts in mood, energy, and activity levels, moving between periods of intense happiness and energy [mania] and periods of sadness and low energy [depression]) and, schizophrenia, unspecified (a chronic brain disorder that affects how a person thinks, feels, and behaves, leading to a disconnection from reality). A review of Resident 22's Physician order dated 5/9/25 indicated, Perphenazine Oral tablet 8 MG Give 2 tablet by mouth two times a day for Schizophrenia During a concurrent interview and record review of Resident 22's clinical records with the DON on 5/30/25 at 12:06 p.m., the DON verified Resident 22 did not have an updated informed consent for the current Perphenazine dose. The DON verified, the informed consent indicated Perphenazine 5 mg to be given 2 tablets twice daily. A review of the facility's policy and procedure (P&P) entitled, Use of Psychotropic Medication (s) revised on 2/5/25, the P&P indicated, .9. Prior to initiating a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase .

Based on interview and medical record review, the facility failed to develop and implement a comprehensive person-centered plan of care for two out of 14 sampled residents (Residents 48 and 22) when: 1. Resident 48 did not have a comprehensive care plan specific to the medication Aripiprazole (an antipsychotic medication used to treat several mental health conditions) and interventions indicated in the care plan were not followed. 2. Resident 22 did not have a comprehensive care plan specific to the medication Perphenazine (used to treat the symptoms of schizophrenia, a mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions). These failures put residents at risk for inadequate monitoring of possible adverse effects specific to their antipsychotic medications. Findings: 1. A review of Resident 48's clinical record indicated an admission date of 3/25/25 and diagnoses included anxiety disorder, unspecified (a mental health condition where excessive worry, fear, and apprehension interfere with daily life), depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in previously enjoyable activities), and unspecified mood [affective] disorder (a mental health condition characterized by persistent and significant changes in a person's mood, thoughts, and behaviors). A review of Resident 48's Physician Order indicated, Abilify Oral Tablet 5 MG [milligram, a unit of measurement] (Aripiprazole) Give 1 tablet by mouth at bedtime for UNSPECIFIED MOOD [AFFECTIVE] DISORDER M/B mood swing, hallu [hallucinations] GDR [gradual dose reduction, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose] ordered on 5/13/25. A review of Resident 48's nursing care plan interventions initiated on 3/26/25 indicated, Complete AIMS [Abnormal Involuntary Movement Scale, used to assess the presence and severity of unwanted, involuntary movements in patients, particularly in areas like the face, mouth, limbs, and trunk] assessment every 6 months and with each increase in dose of antipsychotics During a concurrent interview and record review of Resident 48's clinical records with the Director of Nursing (DON) on 5/30/25 at 11:50 a.m., the DON verified there was no care plan specific for the medication Aripiprazole. The DON also verified Resident 48 did not have a baseline AIMS. The DON also verified Aripiprazole had a black box warning (the strongest warning the U.S. Food and Drug Administration (FDA) can place on a drug label. It indicates a serious, life-threatening side effect or a high risk of harm associated with the medication). During a concurrent interview and record review on 5/30/25 at 3:41 p.m. with the pharmacist consultant (PC), the PC stated a baseline AIMS would be appropriate. A review of facility's policy and procedure (P&P) entitled, Use of Psychotropic Medication (s) revised on 2/5/25, the P&P indicated, .13. AIMS monitors Parkinsonian Symptoms [problems with movement, including shaking (tremor), stiffness (rigidity), and slow movement (bradykinesia), as well as balance issues] such as Extrapyramidal symptoms [side effects caused by certain medications, particularly antipsychotics, that affect the motor system] 14. The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as: d. In accordance with the nurse assessments and medication monitoring parameters consistent with the clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care . A review of facility's policy and procedure (P&P) entitled Resident Rights revised on 3/4/25, the P&P indicated, .2. Planning and implementing care .a .iv. The right to receive the services and/or times included in the plan of care. 2. A review of Resident 22's clinical records indicated an initial admission date of 9/17/24 and diagnoses included, bipolar disorder, unspecified (a mental health condition where a person experiences extreme shifts in mood, energy, and activity levels, moving between periods of intense happiness and energy [mania] and periods of sadness and low energy [depression]) and, schizophrenia, unspecified (a chronic brain disorder that affects how a person thinks, feels, and behaves, leading to a disconnection from reality). A review of Resident 22's Physician order dated 5/9/25 indicated, Perphenazine Oral tablet 8 MG Give 2 tablets by mouth two times a day for Schizophrenia During a concurrent interview and record review of Resident 22's clinical records with the DON on 5/30/25 at 12:06 p.m., the DON verified, there was no nursing care plan specific for Perphenazine. The DON stated specific medications were not included in the nursing care plan. The DON also verified Resident 22 had nursing care plans specific to other psychotropic medications (drugs that affect the brain and are used to treat mental health conditions like depression, anxiety, and schizophrenia) such as Bupropion (medication primarily used as an antidepressant ) and Sertraline (medication primarily used as an antidepressant). A review of facility's policy and procedure (P&P) entitled, Use of Psychotropic Medication (s) revised on 2/5/25, the P&P indicated, . 14. The effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis such as: d. In accordance with the nurse assessments and medication monitoring parameters consistent with the clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care . A review of facility's policy and procedure (P&P) entitled, Comprehensive Care Plans revised 2/5/25, the P&P indicated, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality .

Based on interview and record review, the facility failed to ensure the residents received the necessary care and services for one of 14 residents (112) when Resident 112 was admitted with a pacemaker (electric activity-generating device used to treat patients with slow heart rates) but there was no information on the pacemaker found in his clinical record. This failure had the potential to negatively affect the resident's health, well-being, and safety. Findings: Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 112's physician order, dated 5/22/25, indicated Resident 112 had a pacemaker. However, there were no information on the pacemaker such as the cardiologist information, the implant date, the device model, device serial number, lead (a wire that connects a pacemaker to the heart) model, lead serial number, battery longevity, device lower rate and maximum rate, and device checkup period found in Resident 112's clinical record. During an interview with the director of nursing (DON) on 5/30/25, at 2:30 p.m., she reviewed Resident 112's clinical record and was unable to find the information on his pacemaker. The DON stated she would request Resident 112's pacemaker information and keep them in his clinical record. Review of the facility's 2024 policy, Use of Pacemaker, indicated . 4. All documentation about the pacemaker will be placed in the residents' chart and part of their permanent record.

Based on interview and record review, the facility failed to ensure the residents receive the pain management according to their pain levels for one of two residents (53) when the licensed nurses administered Norco (used to relieve severe pain) 5-325 milligrams (mg, a metric unit of mass) to Resident 53 when she did not have severe pain. This failure had the potential for Resident 53 to experience unnecessary adverse effects from the pain medication. Findings: Review of Resident 53's admission Record indicated she was admitted to the facility on [DATE] with aftercare following joint replacement surgery diagnosis. Review of Resident 53's physician order, dated 5/1/25, indicated she had an order for Norco 5-325 mg one tablet every 4 hours as needed for severe pain level 7-10. Review of Resident 53's 5/2025 Medication Administration Record (MAR) indicated the licensed nurses administered Norco 5-325 mg one tablet to Resident 53 when her pain level was less than 7 on 5/4/25 at 5:09 a.m., 5/6/25 at 9:22 a.m., 5/9/25 at 05:02 a.m., 5/9/25 at 9:45 a.m., 5/10/25 at 9:56 a.m., 5/12/25 at 10:35 a.m., 5/13/25 at 9:06 a.m., 5/13/25 at 2:40 p.m., 5/14/25 at 1:07 a.m., 5/14/25 at 5:42 a.m., 5/15/25 at 8:51 a.m., 5/17/25 at 9:30 a.m., 5/17/25 at 6:25 p.m., 5/18/25 at 4:36 a.m., 5/18/25 at 11:12 a.m., 5/18/25 at 8:19 p.m., 5/20/25 at 5:10 a.m., 5/24/25 at 7:59 p.m., 5/25/25 at 2:33 p.m., 5/26/25 at 4:37 a.m., 5/26/25 at 8:34 a.m., 5/26/25 at 1:57 p.m., and on 5/27/25 at 4:35 a.m. During an interview with the director of nursing (DON) on 5/30/25, at 2:43 p.m., she reviewed Resident 53's 5/2025 MAR and confirmed that the licensed nurses administered Norco 5-325 mg one tablet to Resident 53 when her pain level was less than 7 on 5/4/25 at 5:09 a.m., 5/6/25 at 9:22 a.m., 5/9/25 at 05:02 a.m., 5/9/25 at 9:45 a.m., 5/10/25 at 9:56 a.m., 5/12/25 at 10:35 a.m., 5/13/25 at 9:06 a.m., 5/13/25 at 2:40 p.m., 5/14/25 at 1:07 a.m., 5/14/25 at 5:42 a.m., 5/15/25 at 8:51 a.m., 5/17/25 at 9:30 a.m., 5/17/25 at 6:25 p.m., 5/18/25 at 4:36 a.m., 5/18/25 at 11:12 a.m., 5/18/25 at 8:19 p.m., 5/20/25 at 5:10 a.m., 5/24/25 at 7:59 p.m., 5/25/25 at 2:33 p.m., 5/26/25 at 4:37 a.m., 5/26/25 at 8:34 a.m., 5/26/25 at 1:57 p.m., and on 5/27/25 at 4:35 a.m. The DON stated the licensed nurses should administer pain medication to the residents according to the pain level as ordered by the physician. Review of the facility's job description, Registered Nurse, dated 11/13/17, indicated . Medication and Treatment Administration Functions: . Complies with professional standards, policies and procedures, and legal documentation principles for administering medications, treatments, enteral, and intravenous therapies.

Based on observation, interview, and record review, the facility failed to ensure the proper use of side rails or bed rails (adjustable rigid bars attached to the side of a bed) for two of 20 residents who used side rails, (Residents 19 and 28), when their side rail assessments (determine the appropriateness and safety of using side rails on a bed for an individual) were not updated in a timely manner. This failure had the potential to place the residents at risk for entrapment (danger for the resident, being caught, trapped or entangled in the gap, space or opening) that may lead to injury or death. Findings: 1. During an observation of Resident 19, on 5/27/25 at 10:38 a.m., Resident 19 was in bed, alert, calm, comfortable and verbally responsive. Resident 19's one fourth (quarter) side rail was up. Review of Resident 19's admission record (document created when a resident is admitted to a healthcare facility, containing the vital information about the resident), indicated, Resident 19 was readmitted to the facility on [DATE] with the primary diagnosis of unspecified arthropathic psoriasis (long-term inflammatory arthritis that may occur in some people affected by the autoimmune disease psoriasis). Review of Resident 19's physician orders indicated, Resident 19 had an order on 2/21/24 for side rails for prompt bed mobility. Review of Resident 19's side rail assessment indicated, it was last updated on 2/12/25. During the concurrent review of the side rail assessment of Resident 19 and interview with the Director of Nursing (DON), on 5/30/25 at 1:05 p.m., the DON acknowledged that the side rail assessment of Resident 19 was not updated regularly or quarterly. The DON further acknowledged that Resident 19's side rail assessment was last updated on 2/12/25 and it should have been updated already at this time. 2. During an observation of Resident 38, on 5/27/25 at 10:30 a.m., Resident 38 was laying in his bed, alert, calm, comfortable and verbally responsive. Resident 38 had his bilateral (both sides), half side rails up. Review of Resident 38's admission record indicated, Resident 38 was readmitted to the facility on [DATE] with the primary diagnosis of unspecified displaced fracture (occurs when bone is broken and the broken pieces are not aligned) of third cervical vertebra (part of the seven vertebrae that makes up the neck), subsequent encounter for fracture with routine healing (healing of the fracture is progressing as expected). Review of Resident 38's physician orders indicated, Resident 38 had an order on 2/12/25 for side rails for bed mobility. Review of Resident 38's side rail assessment indicated, it was last updated on 1/7/25. During the concurrent review of the side rail assessment of Resident 38 and interview with the DON, on 5/30/25 at 1 p.m., the DON verified that the side rail assessment of Resident 38 was not updated regularly or quarterly. The DON further verified that Resident 38's side rail assessment was last updated on 1/7/25 and it should have been updated already. Review of the facility's policy and procedure titled, Proper Use of Bed Rails, implemented on October 2022 indicated, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails .The facility will continue to provide necessary treatment and care to the resident who has bed rails in accordance with professional standards of practice and the resident's choices .Responsibilities of ongoing monitoring and supervision are specified as follows: A nurse assigned to the resident will complete reassessments in accordance with the facility's assessment schedule, but not less than quarterly, upon significant change in status, or change in the type of bed/mattress/rail .

Based on interview and record review, the facility failed to ensure the effective use of medications for one of 14 residents (112) when Resident 112 received Ferosul (iron, used for prevention/treatment of iron deficiency) and Calcium Citrate (a medication used to prevent or treat low blood calcium levels) at the same time. This failure had the potential for the residents to not receive the amount of prescribed iron supplements. Findings: Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 112's clinical record indicated, he had physician orders for Ferosul 325 milligrams (mg, a metric unit of mass) every 48 hours for anemia (a problem of not having enough healthy red blood cells to carry oxygen to the body's tissues) at 9 a.m., started on 5/23/25, and for Calcium Citrate 250 mg every day at 9 a.m. and 5 p.m., started on 5/22/25. Thus, since 5/23/25, Ferosul and Calcium Citrate were given at the same time at 9 a.m. every 48 hours. During an interview with the pharmacist consultant (PC) on 5/30/25, at 1:56 p.m., she stated Ferosul and Calcium Citrate should be administered at least two hours apart due to drug-to-drug interaction that decreases the absorption of iron. According to Lexicomp (www.[NAME].com), a nationally recognized drug information resource, the concurrent use of calcium and ferrous sulfate led to a drug-drug interaction (DDI) of Risk Rating D, which was a significant interaction and required therapy modification. The effect of DDI was that the calcium may decrease the absorption of oral preparations of iron salts. It indicated the iron absorption decreased an average of 60% when given as ferrous sulfate and co-administered with calcium. Lexicomp also indicated to separate the administrations of these medications so it may minimize the potential for significant interaction. Review of the facility's 2023 policy, Adverse Drug Interactions, indicated The pharmacy will perform an initial assessment of the complete medication profile for potential adverse drug interactions and other contraindications or precautions on all new patient orders at the time of admission. The pharmacy will perform continual and ongoing assessment of the complete medication profile for adverse interactions and other contraindications for each new order received thereafter.

Based on interview and record review, the facility failed to ensure the pharmacist consultant's recommendation was acted upon for one of 14 residents (115) when Resident 115's administration record on alendronate (used to prevent and treat osteoporosis [thinning of the bone]) did not include the information the pharmacist consultant asked to be included. This failure had the potential for Residents 115 to receive ineffective medication and adverse effects that could negatively impact her health and well-being. Findings: Review of Resident 115's admission Record indicated she was admitted to the facility on [DATE] with osteoporosis diagnosis. Review of Resident 115's Consultation Report, dated 5/20/25, indicated the pharmacist consultant recommended to include in Resident 115's administration record on alendronate the following information: Administer intact tablet at least 30 minutes before the first food, beverage, or medication of the day with 6 to 8 ounces of plain water. Individuals should not lie down for at least 30 minutes and until after the first food of the day. However, review of Resident 115's administration record on alendronate did not indicate that the pharmacist consultant's recommendation was included. During an interview with the director of nursing (DON) on 5/30/25, at 2:47 p.m., she reviewed Resident 115's clinical record and confirmed that the pharmacist consultant's recommendation for her alendronate was not acted upon. Review of the facility's policy, Medication Regimen Review (MRR), dated 4/9/25, indicated . Policy Explanation and Compliance Guidelines: . 7. Timelines and responsibilities for MRR: . f. Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on interview and record review, the facility failed to ensure one of 6 residents (112) were free from unnecessary medications when Resident 112 received dabigatran etexilate mesylate (a blood thinner to prevent blood clots) but was not monitored for the side effects and not care-planned on the use of the medication. This failure had the potential for Resident 112 to experience unrecognized adverse effects. Findings: Review of Resident 112's admission Record indicated he was admitted to the facility on [DATE]. Review of Resident 112's physician order, dated 5/23/25, indicated he had an order for dabigatran etexilate mesylate 110 milligrams (mg, a metric unit of mass) two times a day. However, review of Resident 112's clinical record did not indicate that Resident 112 was monitored for the side effects and was care-planned on the use of the medication. During an interview with the director of nursing (DON) on 5/30/25, at 2:26 p.m., she reviewed Resident 112's clinical record and confirmed that Resident 112 was not monitored for the side effects and was not care-planned on the use of the medication. Review of the facility's policy, Anticoagulant Therapy, dated 8/2014, indicated . Procedure: . 5. Monitor for signs and symptoms of adverse drug effects, including, but not limited to, abnormal or prolonged bleeding, excessive bruising, blood in stool or urine, coffee ground emesis, bleeding from eyes, nose, or gums, etc. 8. Include anticoagulant use and monitoring in care plan.

Based on observation, interview, and record review, the facility had a 12% medication error rate when three medication errors out of 25 opportunities were observed during a medication pass for three out of five sampled residents (Residents 44, Resident 2, and Resident 8) when: 1. Resident 44 did not receive Calcium Carbonate with Vitamin D tablet (used to treat conditions caused by low calcium levels such as bone loss) as ordered by the physician. 2. Resident 2 received Diroximel Fumarate capsule (medication used for the treatment of relapsing forms of multiple sclerosis, a disease that causes breakdown of the protective covering of nerves) without food. 3. Resident 8 did not receive Fluticasone-Salmeterol inhalation (used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma) as ordered by the physician. These failures resulted in medications not given in accordance with the manufacturer's instructions and/or physician's order and had the potential for residents not receiving the full therapeutic effects of medications. Findings: 1. During a medication pass observation on 5/27/25 at 11:27 a.m. with Registered Nurse (RN) E, RN E was preparing medications for Resident 44. RN E stated Resident 44 is due to have Calcium Carbonate with Vitamin D but was not available. RN E also stated pharmacy and physician will be notified. A review of Resident 44's Physician Order dated 5/12/25 indicated, Calcium 600 + D oral tablet 500-5 mg-mcg [milligram-microgram, units of measurement] (calcium carbonate-vitamin D) give 1 tablet by mouth three times a day for supplement. During a concurrent interview and record review of Resident 44's Medication Administration Record (MAR) for May 2025 with the Director of Nursing (DON) on 05/29/25 at 3:44 p.m., the DON verified Calcium Carbonate with Vitamin D was not given at 9 a.m. and 1 p.m. on 5/27/25. A review of facility's policy and procedure (P&P) entitled, Medication Administration revised 4/9/25, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . 2. During a medication pass observation on 5/28/25 at 4:03 p.m. with Licensed Vocational Nurse (LVN) F, LVN F was preparing medications for Resident 2 which included, Gabapentin (a medication primarily used as an anticonvulsant) 300 mg (milligram, unit of measurement) tablet, Sucralfate (medication that treats stomach ulcers) 1 gram tablet, and 2 capsules of Diroximel Fumarate 231 mg. Resident 2 took the medications with a glass of water. There was no food tray observed on Resident 2's table. A review of Resident 2's physician order indicated, Vumerity Capsule delayed release 231 mg [milligram, unit of measurement] (diroximel fumarate) give 2 capsules by mouth two times a day for multiple sclerosis, administer at least 20 minutes after food is taken. During a concurrent interview and record review of Resident 2's clinical record with the DON, the DON verified diroximel fumarate was scheduled to be given before dinner. The DON stated the nurse should have asked if Resident 2 had taken food. The DON also stated the medication must be scheduled after meals or a snack should be offered prior to administration. A review of facility's policy and procedure (P&P) entitled, Medication Administration revised 4/9/25, the P&P indicated, .17. Administer medication as ordered in accordance with manufacturer specifications. a. Provide appropriate amount of food and fluid . 3. During a medication pass observation on 5/28/25 at 4:09 p.m. with Licensed Vocational Nurse (LVN) F, LVN F prepared medication for Resident 8 which included, Calcium with Vitamin D3 tablet. LVN F stated Resident 8 was due for a breathing treatment that was not available. Resident 8 took Calcium with Vitamin D3 tablet with a glass of water. A review of Resident 8's physician order indicated, Wixela Inhub Aerosol Powder Breath Activated 250-50 mcg/act [microgram per actuation, a unit of measurement] (fluticasone-salmeterol) 1 puff inhale orally two times a day for asthma rinse mouth after each dose. During a concurrent interview and record review of Resident 8's clinical records with the DON on 5/29/25 at 3:44 p.m., the DON verified fluticasone-salmeterol inhalation was not administered for Resident 8 on 5/28/25 due at 5 p.m. A review of facility's policy and procedure (P&P) entitled, Medication Administration revised 4/9/25, the P&P indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice .

Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were stored appropriately and in good sanitary condition when: 1. Medication refrigerator had ice build up in the freezer and had a streak of yellowish-brown substance on the shelf bracket. 2. Five expired over-the-counter medications, and an opened bottle of medication for a discharged resident were found in the Central Supply Room. These failures put residents at risk for contaminated medications and had the potential for residents to receive outdated and/or ineffective medications which could lead to residents not receiving the full benefit of the medications and negative health outcomes. Findings: 1. During an inspection of the medication room on 5/27/25 at 10:21 a.m. with the Director of Nursing (DON), a mini refrigerator was inside. The DON confirmed there was an ice buildup in the freezer. The DON verified the ice buildup blocked the freezer door and cannot be closed and was hard to open. The DON also verified there was a streak of yellowish-brown substance found inside refrigerator on the right shelf bracket. The DON stated, We could clean it better. A review of facility's policy and procedure (P&P) entitled Medication Storage revised 4/9/25, the P&P indicated, It is the policy of this facility to ensure all medications housed on our premises will be stored in pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security . 2. During an inspection of the Central Supply Room (CSR) on 5/27/25 at 10:30 a.m. with the DON, the DON stated over-the-counter medications and other supplies were stored in the CSR. The DON confirmed the following were stored in the CSR: a. A bottle of Vitamin D3 125 mcg (microgram, unit of measurement) capsules with expiration date 1/2025. b. 2 bottles of Acetaminophen 325 mg (milligram, unit of measurement) tablets with expiration date 12/2024. c. A bottle of Acetaminophen 325 mg (milligram, unit of measurement) tablets with expiration date 8/2024 d. A tube of Zinc Oxide Formula non greasy barrier cream with expiration date 3/2025 e. An opened bottle of Pancrelipase capsules (used to improve digestion of food for people who have a condition in which the pancreas does not have enough enzymes needed to break down food so it can be digested) labeled with a discharged resident's name. The DON stated she did not know why the expired medications were there. The DON also confirmed the opened bottle of Pancrelipase belonged to a discharged resident and should not have been there. A review of facility's policy and procedure (P&P) entitled Medication Storage revised 4/9/25, the P&P indicated, .8. Unused Medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with our Destruction of Unused Drugs Policy.

Based on observation and interview, the facility failed to ensure 17 of 27 bedrooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents receive. Findings: The room measurement indicated multiple rooms were less than 80 square feet per resident. Room Number Number of Beds Square Feet Per Resident 1 3 72.8 5 2 71.37 7 2 71.95 9 2 75 12 3 73.2 14 3 73.2 15 3 73.2 16 3 74 17 3 74 18 2 75 19 2 73.2 20 2 74.4 23 3 73.2 24 3 73.6 25 3 73.6 27 3 73.6 29 3 73.2 During the survey, residents and staff were observed and interviewed to determine if there were any concerns or issues with the lack of space or privacy. The residents and staff verbalized no complaints or concerns regarding space and privacy affecting residents' care. Recommend to continue room waivers.

Based on observation, interview, and document review, the facility failed to ensure food was stored in accordance with professional standards for food service safety when: 1. There was an unlabeled and undated crate of oranges and apples in the dry storage area of the kitchen; 2. There was a dented can of kidney beans in the dry storage area of the kitchen; 3. There was no internal thermometer in two kitchen freezers; and 4. There were multiple brown substances on the metal racks in the kitchen reach-in refrigerator. These failures had the potential to cause food contamination and spread foodborne illness to all residents who received their food from the kitchen. Findings: 1. During an observation and concurrent interview with the dietary manager (DM) on 2/20/24 at approximately 8:56 a.m., there was one unlabeled and undated crate of oranges and apples in the dry storage area of the kitchen. The DM confirmed this observation and stated everything should have a label with the date the food was received. The facility's undated document titled Cook Training/Orientation Checklist indicated, Cover, date, and label stored foods. 2. During an observation and concurrent interview with the DM on 2/20/24 at approximately 8:58 a.m., there was a dented can of kidney beans in the dry storage area of the kitchen. The dented can was stored together with non-dented cans that were intended for resident consumption. The DM confirmed this observation and explained there was a designated area in his office where dented cans should be placed. The facility's policy titled Food Receiving, dated 2/2009 indicated, When unpacking items, you must inspect goods for damage. If you have dented cans or open packages, label them do not use and put them in the supervisor's office to be sent back to the supplier for credit. 3. During an observation and concurrent interview with the registered dietician (RD) on 2/20/24 at approximately 9:05 a.m., three reach-in freezers in the kitchen were inspected. The reach-in freezers had a small screen on the outside that displayed the freezer temperatures. One of the three reach-in freezers had an internal thermometer. The other two reach-in freezers did not have an internal thermometer. The RD confirmed this observation, but was not sure if the reach-in freezers needed to have internal thermometers. The facility's policy titled Food Safety In Receiving and Storage, dated 2/2009 indicated, A thermometer will be kept in each refrigerator and freezer unit. Cooler and freezer temperatures will be checked and recorded daily, using the internal thermometers. The facility's undated policy titled Food & Dining Services Equipment Cleaning Procedures indicated, Freezer: . 5. Verify that there is a thermometer inside the unit. 4. During an observation and concurrent interview with the DM on 2/20/24 at approximately 9:20 a.m., the kitchen's reach-in refrigerator was inspected. The reach-in refrigerator had multiple metal racks with food stored on them. There were multiple brown crusty substances spread throughout all of the metal racks. The DM confirmed this observation. During a follow-up observation and concurrent interview with the DM on 2/21/24 at 8:02 a.m., the kitchen's reach-in refrigerator was inspected again. The brown crusty substances were no longer on the metal racks. The DM confirmed these were the same metal racks from the previous day, but they had been cleaned with soap and water. The United States Food and Drug Administration's 2022 Food Code indicated equipment shall be clean to sight and touch.

Based on observation, interview, and document review, the facility failed to ensure garbage was stored properly when the lid for the outside dumpster was not closed. This failure had the potential to attract insects, rodents, and other pests to the facility. Findings: During an observation and concurrent interview with the dietary manager (DM) and registered dietician (RD) on 2/21/24 at 8:15 a.m., the facility's outside dumpsters were inspected. There was one dumpster designated for garbage. This dumpster had garbage bags inside that were situated in such a way that the bags were stacked above the dumpster's brim, and the dumpster lid was not able to close. Both the DM and the RD confirmed this observation. The DM looked inside the garbage dumpster and stated there was actually more room inside. The DM rearranged the garbage bags and the dumpster lid was then able to close. The RD confirmed the lid to the garbage dumpster should have been closed. The facility's policy titled Garbage & Rubbish Disposal, dated 2/2009 indicated, 2. All containers are provided with tight-fitting lids or covers 5. Garbage and rubbish containing food waste shall be stored so as to be inaccessible to vermin 8. Outside dumpsters provided by garbage pickup services must be kept closed and free of litter around the dumpster area. The United States Food and Drug Administration's 2022 Food Code indicated, Refuse [waste], recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. The Food Code further indicated, Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents.

Based on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered, care plans for four out of seventeen sampled residents, (Residents 217, 29, 47 and 220), when the activity care plans of Residents 217, 29, 47 and 220, were not comprehensive and person-centered. These failures had the potential to result in the residents, not receiving the interventions necessary to maintain their highest level of well-being. Findings: 1. Review of Resident 217's face sheet (a document that gives resident's information at a quick glance) indicated, Resident 217 was admitted to the facility on [DATE] with diagnoses including systemic sclerosis (an autoimmune disorder in which the immune system attacks own body, affecting many systems of the body) with lung involvement, dysphagia (difficulty swallowing), oropharyngeal phase (swallowing problems occurring in the mouth and/or throat) and essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition). During an observation of Resident 217 on 2/20/24 at 12:50 p.m., Resident 217 was laying in her bed, alert, calm and verbally responsive. Review of Resident 217's active physician orders as of 2/21/24 indicated, Resident 217 may participate in activities, reviewed and approved, when not in conflict with treatment, ordered on 2/2/24. During the interview with the activity director (AD), on 2/22/24 at 3:39 p.m., AD stated that the activity assistant (AA), goes to Resident 217's room for room visits and to check on Resident 217, twice per day. Review of Resident 217's care plans indicated, Resident 217 did not have room visits in the interventions of her activity care plan and there were no specific activities to be provided during the room visits. Resident 217's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 217's activity care plan and interview with AD, on 2/23/24 at 11:15 a.m., AD verified, Resident 217 did not have room visits in the interventions of her activity care plan and there were no specific activities to be provided during the room visits. AD further verified, Resident 217's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 217 should have comprehensive, person-centered activity care plan and she will update Resident 217's activity care plan. During a concurrent record review of Resident 217's activity care plan and interview with the director of nursing (DON), on 2/23/24 at 2:17 p.m., DON verified, Resident 217 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 217 should have comprehensive, person-centered activity care plan. 2. Review of Resident 29's face sheet indicated, Resident 29 was readmitted to the facility on [DATE] with diagnoses including osteomyelitis of vertebra (rare spine infection, causing weakness in it's structure or pressure on the spinal cord or nerve roots), lumbar region (lower back), Parkinson's disease (disorder of the central nervous system that affects movement, often including tremors) without dyskinesia (uncontrolled, involuntary muscle movement) with fluctuations (irregular shifting) and hyperlipidemia (high levels of fat particles in the blood). During an observation of Resident 29 on 2/20/24 at 10:38 a.m., Resident 29 was sitting in his wheelchair, alert, calm and comfortable. Review of Resident 29's active physician orders as of 2/21/24 indicated, Resident 29 may participate in activities, reviewed and approved, when not in conflict with treatment plan, ordered on 1/19/24. During the interview with the activity director (AD), on 2/22/24 at 3:39 p.m., AD stated that they try to do one-on-one with Resident 29 in the activity room, usually with iPad (a touchscreen tablet computer, smaller than a typical laptop, made by Apple Incorporated, an American manufacturer of personal computers, smartphones, tablet computers, computer peripherals and computer software and one of the most recognizable brands in the world). Review of Resident 29's care plans indicated, Resident 29 did not have specific activities to be provided during his one-on-one visits, in the interventions of Resident 29's activity care plan. Resident 29's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 29's activity care plan and interview with AD, on 2/23/24 at 11:18 a.m., AD verified, Resident 29 did not have specific activities to be provided during his one-on-one visits, in the interventions of Resident 29's activity care plan. AD further verified, Resident 29's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD further verified that Resident 29 should have comprehensive, person-centered activity care plan and she will update Resident 29's activity care plan. During a concurrent record review of Resident 29's activity care plan and interview with the DON, on 2/23/24 at 2:20 p.m., DON verified, Resident 29 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 29 should have comprehensive, person-centered activity care plan. 3. Review of Resident 47's face sheet indicated, Resident 47 was readmitted to the facility on [DATE] with diagnoses including other displaced fracture (the ends of the bone have come out of alignment) of third cervical vertebra (one of the seven cervical vertebrae of the neck and the most superior one), subsequent encounter for fracture (a partial or complete break in the bone) with routine healing, type 2 diabetes mellitus (adult onset high blood sugar) and unspecified liver cirrhosis (chronic liver damage from a variety of causes leading to scarring and liver failure). During an observation of Resident 47 on 2/20/24 at 10:38 a.m., Resident 47 was sitting in his chair, alert, oriented, calm and comfortable. Review of Resident 47's active physician orders as of 2/21/24 indicated, Resident 47 may participate in activities, reviewed and approved, when not in conflict with treatment plan, ordered on 2/15/24. During the interview with the activity director (AD), on 2/22/24 at 3:57 p.m., AD stated that the activity assistant (AA), goes to Resident 47's room for room visits and to check on Resident 47, twice per day. Review of Resident 47's care plans indicated, Resident 47 did not have room visits in the interventions of his activity care plan and there were no specific activities to be provided during the room visits. Resident 47's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 47's activity care plan and interview with AD, on 2/23/24 at 11:21 a.m., AD verified, Resident 47 did not have room visits in the interventions of his activity care plan and there were no specific activities to be provided during the room visits. AD further verified, Resident 47's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 47 should have comprehensive, person-centered activity care plan and she will update Resident 47's activity care plan. During a concurrent record review of Resident 47's activity care plan and interview with the DON, on 2/23/24 at 2:23 p.m., DON verified, Resident 47 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 47 should have comprehensive, person-centered activity care plan. 4. Review of Resident 220's face sheet indicated, Resident 220 was admitted to the facility on [DATE] with diagnoses including hypo-osmolality (a condition where the levels of electrolytes, proteins and nutrients in the blood are lower than normal) and hyponatremia (low blood sodium), essential primary hypertension (abnormally high blood pressure that's not the result of a medical condition) and malignant neoplasm (cancerous tumor which develops when abnormal cells grow, multiply and spread to other parts of the body) of unspecified site of unspecified female breast. During an observation of Resident 220 on 2/20/24 at 11:35 a.m., Resident 220 was laying in her bed, alert, oriented, calm and comfortable. Review of Resident 220's active physician orders as of 2/21/24 indicated, Resident 220 may participate in activities, reviewed and approved, when not in conflict with treatment plan, ordered on 2/5/24. During the interview with the activity director (AD), on 2/22/24 at 4:02 p.m., AD stated that the activity assistant (AA), goes to Resident 220's room for room visits and to check on Resident 220, twice per day. Review of Resident 220's care plans indicated, Resident 220 did not have room visits in the interventions of her activity care plan and there were no specific activities to be provided during the room visits. Resident 220's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. During a concurrent record review of Resident 220's activity care plan and interview with AD, on 2/23/24 at 11:25 a.m., AD verified, Resident 220 did not have room visits in the interventions of her activity care plan and there were no specific activities to be provided during the room visits. AD further verified, Resident 220's activity care plan, was not comprehensive and person-centered, that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. AD then stated that Resident 220 should have comprehensive, person-centered activity care plan and she will update Resident 220's activity care plan. During a concurrent record review of Resident 220's activity care plan and interview with the DON, on 2/23/24 at 2:27 p.m., DON verified, Resident 220 did not have comprehensive, person-centered activity care plan. DON further verified, Resident 220 should have comprehensive, person-centered activity care plan. Review of the facility's policy and procedure titled, Care Plan, Comprehensive, dated 2008 indicated, It is the policy of this facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The care plan is directed toward achieving and maintaining optimal status of health, functional ability and quality of life. The care plan is individualized by identified resident problems, unique characteristics, strengths and individual needs. Each plan should be realistic and have measurable goals and time frames and responsibility for meeting the specific goals.

Based on interview and record review, the facility failed to revise, and evaluate care plan effectiveness at minimizing falls and injuries for one of three sampled residents (Resident 1).This failure resulted in Resident 1's four fall incidents with the fourth fall incident (FALL#4) sustaining a large laceration (deep cut or tear on skin) on his forehead that required eleven sutures (surgical stitches to hold together the edges of a laceration) for closure. Findings: Review of Resident 1's clinical record indicated he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. His initial fall risk assessment on 12/5/19 scored 51, on 1/6/2020 scored 55, the Morse fall score of 45 and higher is considered high risk for falls. His minimum data set (MDS, an assessment tool) dated 12/7/19, indicated a brief interview for mental status (BIMS, determines a resident's attention, orientation and ability to register/recall information) score was 3, which indicated he had severe cognitive impairment. His functional status indicated he required extensive assistance by 2 staff with transfers, and only able to stabilize with staff assistance in moving from seated to standing position. During an interview on 1/17/2020 at 10:37 a.m., with certified nursing assistant A (CNA A), he stated Resident 1 was confused, always taking out his clothes, required two staff during care as, he was always fighting when we change him, it was hard to change him. During an interview on 1/17/2020 at 11:10 a.m., with the assistant director of nursing (ADON), she stated Resident 1 liked to reposition in bed frequently, his habit was to reposition himself in bed, put his head to the foot of the bed and back and, also takes his clothes off. Review of Resident 1's clinical record revealed he had four falls from 12/12/19 to 1/13/2020, all occurred during the night shift: FALL#1 -12/12/19 06:30, unwitnessed, was found on the floor by a staff; FALL#2 -12/21/19 03:00, witnessed, was assisted to floor mat when rolling off edge of the bed; FALL#3 -1/10/2020 00:00, unwitnessed, nurse on duty found Resident 1 on the floor and; FALL#4 -1/13/2020 0:100, unwitnessed, Resident 1 was heard yelling, staff checked and found him sitting on the floor mat with a large laceration on middle of his forehead with significant bleeding. Review of Resident 1's long term care plan (LTCP) initiated on 12/5/19, High Risk for falls and injuries related to medications: [REDACTED]. Review of Resident 1's short term care plan (STCP), The resident has had an actual fall, included additional new interventions initiated after each fall. Review of Resident 1's fall care plan after FALL#1 dated 12/13/19, indicated floor mat and low bed. Review of Resident 1's fall care plan after FALL#2 dated 12/21/19, indicated keep urinal and personal stuff within reach. Review of Resident 1's fall care plan after FALL#3 dated 1/10/2020, indicated frequently check on resident before bed and at around midnight and every two hours. Review of Resident 1's fall care plan after FALL#4 dated 1/13/2020, indicated pad the night stand, take away the bedside table, install grab bar. Review of Resident 1's fall care plan interventions for FALL#2 indicated this intervention was already in the LTCP. During an interview on 1/17/2020 at 11:10 a.m., with the ADON, she reviewed the fall reports and the interdisciplinary (IDT, interdisciplinary team) recommendations after FALL#1, FALL#2 and FALL#3 for Resident 1, when asked if these interventions were enough, she stated, he fell again. Review of Resident 1's emergency department provider notes from the hospital dated 1/13/2020, indicated Resident 1 had approximately 5 cm [MEDICAL CONDITION] and required 11 sutures for closure. Review of the facility's policy, dated (MONTH) 2014, Fall Management, indicated fall prevention procedure include: evaluate risk factors for sustaining falls upon admission, with comprehensive assessments, and while conducting interdisciplinary care plan reviews; initiate a fall prevention care plan when appropriate with strategies to minimize risk and potential for injuries and; review, revise, and evaluate care plan effectiveness at minimizing falls and injuries during IDT walking rounds and as needed Procedure for responding to a fall include: review, revise, and update care plan accordingly, evaluate actual or suspected causal factors to prevent recurrences.

Based on observation, interview and record review the facility failed to ensure the safe use of Point of Care diagnostic blood clotting test for five of 19 sampled residents (Residents 6, 11, 16, 17, 18), when: 1. There was no documented evidence that the licensed nurses had adequate training to conduct the test; 2. There was no documented evidence that the CoaguChek XS systems were regularly maintained according to the manufacturer's recommendation. This deficient practice had the potential to result in hypo (insufficiency of the blood to clot and stem bleeding properly) or hyper-coagulation (excessive bleeding) treatment, which could lead to clotting or severe bleeding. The findings constituted an Immediate Jeopardy situation. The facility staff had knowledge of the lack of adequate training and maintenance of the CoaguChek machine. There were a total of five residents on anticoagulant medication whose INR (International Normalized Ratio - clotting test) was monitored using the CoaguChek XS device. One resident (Resident 11) was transferred to an acute care hospital for profuse bleeding from an A-V shunt (a surgically created vein used to remove and return blood during [MEDICAL TREATMENT]) site. According to the manufacturer's Policy and Procedures Manual, Section I: Systematic Anticoagulation Management (SAM) Program Overview, Anticoagulation is a high-risk treatment that can lead to adverse events due to the complexity of dosing anticoagulant in medications, monitoring their effects, and ensuring patient compliance . Findings: 1. Review of the Face Sheet indicated Resident 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Resident 6's Order Summary Report, dated 7/1/16, indicated an order to give [MEDICATION NAME] (a blood thinner medication) and . check in house INR (International Normalized Ratio: a clotting test) . Review of the Face Sheet indicated Resident 11 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED].[MEDICATION NAME] Sodium (also known by the brand name [MEDICATION NAME], a blood thinner) give 1.5 mg (milligram) by mouth at bedtime for [MEDICAL CONDITION] Fibrillation. Next INR in house on 6/27/16 Review of Situation, Background, Assessment, Recommendation (SBAR) - COC (change of condition), 911 Transfer, dated 6/27/16 Resident 11 had increased INR levels, and was transferred to hospital on [DATE] at 8:54 pm, due to: .profusely bleeding from AV shunt (a surgically created vein used to remove and return blood during [MEDICAL TREATMENT]) site . on the left arm. In an interview on 6/28/26 at 10:55 am, the Nursing Supervisor (NS) 1 stated the facility was using the CoaguChek machine as a Point of Care monitoring device for about one and a half years to determine the INR level. NS 1 stated only Licensed Nurses (LN) were allowed to use the monitoring device. NS 1 was trained and other LN's trained each other. There were a total of five residents on anticoagulant medication whose INR was monitored using the CoaguChek machine. Review of the manufacturer's manual, copyright dated 2008-2012, indicated all operators should have been properly trained and certified to perform CoaguChek XS tests on patients, as required by the federal Clinical Laboratory Improvement Amendments (CLIA) of 1988. Operator Training/Certification: . CoaguChek XS operators have documented training for the test that they are authorized to perform. A CoaguChek XS Operator Certification Checklist is completed for each operator. Keep a copy of the CoaguChek XS Operator Certification Checklist for at least 2 years . Review of the facility's Anti-Coagulant Point of Care Monitoring, dated 2008, indicated that nurses must complete specific training on the proper and safe use of Point of Care monitoring, and its maintenance. In an observation on 6/29/16 at 10:25 A.M., LVN 1 stated she would perform fingerstick (clotting test) on Resident 16 to check the INR level. LVN 1, turned on the power of the monitoring device, using a lancet, pricked the skin and a small amount of blood came out unto the strip. LVN 1 squeezed Resident 16's finger again to obtain an additional drop of blood to place on the test strip. LVN 1 stated the result was 2.6. Review of the manufacturer's manual, copyright dated 2008-2012, indicated: .Fingerstick Blood Collection Procedure: . Immediately after lancing, massage gently along the side of the finger to obtain a good drop without pressing or squeezing too hard.Do not apply a second drop of blood or disturb the strip while testing. In an interview on 6/29/16 at 10:11 am, the Licensed Vocational Nurse (LVN) 1 stated she was hired on August 2015 and was trained on the use of the Coaguchek machine by the Director of Staff Development (DSD). In an interview on 6/30/16 at 9:23 am, the DSD stated she had not used the CoaguChek machine and had no training in its use. In an interview and concurrent document review with the DSD on 6/30/16 at 9:20 am, she stated there was no record on file of the Training and Certification of the prior DSD. The DSD acknowledged the only document on file was the In-Service Record dated 9/19/14. The DSD stated there was no record of the Competency Skills and Certificates for all the 7 attendees of which only two were still employed in the facility. There was no documented evidence that the prior DSD who provided the in-service on 9/19/14 had been trained and certified in the use of the CoaguChek machine. In an interview on 6/30/16 at 10:15 A.M., the Regional Director of Clinical Operations (RDCO) verified there was no record of the Training and Certification for the use of the Coaguchek machine of the prior DSD on file. RDCO stated usually the vendor would do an in-service for new products. In an interview on 7/5/16 at 12:02 P.M., the Administrator verified the vendor had no record of the prior DSD's Certification for the use of the CoaguChek machine. In an interview on 7/1/16 at 12:15 pm, NS 1 stated she watched the video during the training on 9/19/14 and acknowledged there was no Competency Skills Checklist completed and no Certification issued. In an interview with the Licensed Vocational Nurse (LVN) 1 on 7/5/16 at 8:15 am, LVN 1 acknowledged there were no training and competency skills done by the DSD. LVN 1 stated we trained each other. In an interview on 7/5/16 at 2:20 pm, the interim DON acknowledged the staff should follow manufacturer's recommendations. In an interview on 6/30/16 at 2:10 pm, the Administrator verified there was no training in the use of the CoaguChek machine for all the new hired Licensed Nurses from 2015 to 2016. Review of the Face Sheet indicated Resident 16 was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of Resident 16's Clinical physician's orders [REDACTED]. In an interview on 6/29/16 at 10:30 am, LVN 1 stated she would use the Bleach Wipes to clean the CoaguChek machine, leave it for a minute and dry with paper towel. In an interview on 6/29/16 at 1:11 pm, NS 1 stated she used the Bleach Wipes, before and after using the CoaguChek machine. for one minute and let it dry before wiping. Review of the manufacturer's manual, copyright dated 2008 -2012, indicated: .Failure to follow these procedures may cause malfunction of the meter. Cleaning /disinfecting the meter housing (the exterior of the meter) use only . 70% [MEDICATION NAME] alcohol, 10 % Sodium hypochlorite solution (1 part bleach to 9 parts de-ionized water made fresh every 24 hours) for a contact time of > (greater) than 1 (one) minute .NOTE: DO NOT use any other disinfectants/cleaning solutions on the meter housing .Use of other cleaning/disinfecting solutions could result in damage to the meter . In an interview on 6/29/16 at 1:18 pm, NS 1 stated about 2 weeks ago, one machine had a problem, and it just needed more blood. NS 1 continued to state the procedure was repeated and the machine gave the result. NS 1 verified there was no sample of blood sent to the laboratory for comparison. Review of facility policy on Anti-Coagulant Point of Care, 2008, Policy Number: no written information. Error Messages: Error: . 5, Reason: Error in applying blood to the test strip. Solution: turn the meter off and removed the test strip. Repeat the test using a new test strip and blood taken from a new finger stick as necessary. Error 7, Measurement Error, Reason: Measurement error caused by the blood sample, Solution: Do not touch or remove the test strip when the test is in progress. In rare cases, Error Message 7 can occur in patients with long coagulation times (>8 INR). If this occurs . facilitate STAT INR testing through the facilities external lab provides . In an interview on 6/29/16 at 9:58 am, Central Supply Staff (CSS), stated he started the position about two months ago, verified he was responsible for the preventative maintenance of the CoaguChek machine. CSS stated there was no maintenance log done by the prior CSS. CSS acknowledged the monitoring device did not have a bio-med sticker (electric and mechanical safety checks performed on medical equipments) attached to the CoaguChek machine. CSS could not provide evidence of monthly QA maintenance on the CoaguChek machine. In an interview on 7/5/16 at 12:00 pm, the Administrator stated there was no discussion in the QA (Quality Assurance) meetings about the use of the CoaguChek machine and no record on file that it was discussed in the past. In an interview on 7/5/16 at 8:35 am, the Medical Director verified there was no discussion brought up in the QA meeting with regards to the CoaguChek machine. Review of the manufacturer's manual, copyright dated 2008-2012, indicated: . Section 8: Quality Assessment. QA (Quality Assurance) Policies: . The Monthly QA Checklist is a means of ongoing assessment, which helps to evaluate how well our systematic anticoagulation management program is working. QA procedure: Once a month complete the Monthly QA Checklist including the chart review portion. If an item is marked no, then take action and document that action on the Monthly QA Checklist Action to take involves determining a quality measure was not taken. An Immediate Jeopardy was called on 6/30/16, at 5:06 pm with the Administrator, Director of Nursing and Regional corporate staff. The Administrator, Director of Nursing and Regional corporate staff were verbally informed of the facility's failure to ensure the safe use of Point of Care diagnostic blood clotting test. The Immediate Jeopardy was removed on 7/1/16 at 4:01 pm, after an acceptable plan of correction was presented by the Administrator, Director of Nursing and Regional corporate staff. The Plan of Correction included: 1. The CoaguChek machines were taken out of service permanently and secured in the DON's office. 2. A contract was agreed upon for an outside lab provider to complete blood testing and provide result for all residents who require INR testing. 3. The resident who had INR completed on 6/30/16, using the CoaguChek machine had the sample redrawn by the outside lab provider. The above were verified by the survey team.

Based on observation, interview, and record review the facility failed to provide the necessary nursing care and intervention for one out of 21 sampled residents (Resident 11) when: 1. Resident 11's International Normalized Ratio (INR - blood clotting test) was 4.3 (In healthy people, an INR of 1.1 or below is considered normal. An INR range of 2.0 to 3.0 is generally an effective therapeutic range for people on blood thinner). This abnormal INR result was not communicated to the [MEDICAL TREATMENT] center; 2. staff failed to effectively manage the bleeding at Resident 11's Arterial/venous (AV, a surgical connection of an artery and vessel for [MEDICAL TREATMENT] access) graft site; 3. the facility did not have any policy and procedure to address emergency procedure for excessive bleeding from an AV graft site. These failures resulted in Resident 11's experiencing excessive bleeding to her AV shunt site and subsequent transfer to the ER where the AV shunt was sutured. The facility used a medical device to check Resident 11's INR level. According to the INR device manufacturer's Policy and Procedures Manual, Section I: Systematic Anticoagulation Management (SAM) Program Overview, Anticoagulation is a high-risk treatment that can lead to adverse events due to the complexity of dosing anticoagulant in medications, monitoring their effects, and ensuring patient compliance . Findings: Review of Admission Record, indicated Resident 11 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of Minimum Data Set (MDS, an assessment tool), dated 4/17/16, showed Resident 11 had Brief Interview for Mental Status (BIMS, a test to determine cognition level) score of 15, indicating normal cognition level. During an interview on 6/30/16 at 9:01 AM, Resident 11 stated, I'm cold I don't want to remove my jacket, and that her vascular access (a surgically created vein used to remove and return blood during [MEDICAL TREATMENT]) was on her left upper arm. She also stated she goes to [MEDICAL TREATMENT] early morning every Monday, Wednesday, and Friday. Review of physician's orders [REDACTED].[MEDICATION NAME] Sodium (also known by the brand name [MEDICATION NAME], a blood thinner) give 1.5 mg (milligram) by mouth at bedtime for [MEDICAL CONDITION]. Next INR in house on 6/27/16 There was no target range of INR indicated at the Physicians Order. Review of American Heart Association (AHA) and American College of Cardiology Association Guidelines in Management of Patient with [MEDICAL CONDITION] Fibrillation (A fib, irregular heart beat with increased risk of blood clots) (2011) indicated, . Therapy For Patient With [MEDICAL CONDITION] Fibrillation .Recommended . INR 2.0 to 3.0, target 2.5 . Review of Resident's SNF (skilled Nursing Facility) Visit Note, dated 5/23/16, indicated because she had A fib, her physician wanted her INR GOAL (to be between) 2-2.5 . Review of Resident 11's INR Result dated 6/27/16, indicated Resident 11 ' s INR was 4.3. Staff failed to document the time when this INR was taken. Review of Resident 11's SBAR (Situation, Background, Assessment, Recommendation) Communication Form, dated 6/27/16 at 8:42 PM indicated, Situation: Elevated INR: 4.3. This started on 6/27/16, Morning .Medication alerts: Resident is on [MEDICATION NAME]/[MEDICATION NAME] . Assessment: Patient INR taken before going out for [MEDICAL TREATMENT] appointment at 8 am. No signs of bleeding noted prior to appointment . Review of Resident 11's SBAR COC (change of condition) 911 Transfer dated 6/27/16 at 8:54 PM, indicated, .Situation: Left upper arm AV shunt profusely bleeding. This started on 6/27/16 . Increased INR levels, patient had [MEDICAL TREATMENT] in the morning, profusely bleeding from AV shunt site . Review of Resident 11's Emergency Department (ED) Transfer Summary dated 6/27/16, .ED arrival information: Arrival 6/27/16 at 9:16 PM; Acuity: 3-Urgent .Chief Complaint: Shunt Problem. Bleeding from [MEDICAL TREATMENT] shunt in the left upper arm since 11 AM. Completed [MEDICAL TREATMENT] today . Laboratory Result: INR 3.8, collection time 6/27/16 at 22:13 pm. During document review and concurrent interview on 7/1/16 at 1:52 pm, the Regional Director of Clinical Operations (RDCO) acknowledged Resident 11 ' s abnormal INR result of 4.3 on 6/27/16 was not included in the [MEDICAL TREATMENT] Care Communication/Coordination form from the facility to the [MEDICAL TREATMENT] center. RDCO stated, Yes, it's not there, it should've been there. RDCO also acknowledged an abnormal INR was important clinical information and should be communicated to the [MEDICAL TREATMENT] center. RDCO further stated I would need to notify anything abnormal. During interview on 7/5/16 at 8:58 am, the Medical Director stated, I agree that the result of INR should have been communicated to the [MEDICAL TREATMENT] center. Progress notes and relevant data should go with them whenever they go for treatment. The Medical Director stated he .spoke to many nephrologist (doctors specializing in treating kidney diseases) they will check the labs .they do the treatment, they should take care of the INR. Review of facility documentation found no evidence the [MEDICAL TREATMENT] center was performing lab draws on Resident 11. During document review and concurrent interview on 7/1/16 at 1:52 pm, RDCO acknowledged there was no information regarding Resident 11's Emergency Department visit due to excessive bleeding on 6/27/16 written on the [MEDICAL TREATMENT] Care Communication/Coordination form. RDCO stated, I would need to notify any significant change to [MEDICAL TREATMENT] center. Review of [MEDICAL TREATMENT] Treatment Center's Hemo Treatment Log Summary for Resident 11, dated 6/27/16, indicated, Post tx (treatment): no pain and patient stable. Post tx note: discharged alert without any complaint, v/s (vital signs- temperature, pulse rate, rate of breathing, and level of blood pressure) stable, no bleeding post HD ([MEDICAL TREATMENT]) treatment, dressing clean and dry . During an interview on 7/1/16 at 3:24 PM, the Director of Nursing (DON) stated No [MEDICATION NAME] during [MEDICAL TREATMENT] on 6/27/16. She did not receive any [MEDICATION NAME]. Review of the facility's Covenant Care Standard- [MEDICAL TREATMENT] Care, dated September 2007, indicated, .This facility has direct responsibility for the care of the resident .g. Identifying and responding to [MEDICAL TREATMENT] related changes in condition . The facility and the [MEDICAL TREATMENT] center will communicate by telephone or in writing: Any medical or non-medical emergency that may interfere with scheduled [MEDICAL TREATMENT] appointments or treatments .Emergent changes in the resident's condition. Unusual occurrences involving the resident . Review of Satellite Healthcare: LTCF (Long Term Care Facility)- [MEDICAL TREATMENT] ([MEDICAL CONDITION]) Compliance Agreement with a revision date of 6/28/13 indicated, .3. Communication: a. Emergency and non-emergency changes in a resident's medical condition will be promptly communicated by the party having primary knowledge of the change to the other party, regardless of the location of the patient at the time of the change . 2. During an interview on 6/30/16 at 9:01 AM, Resident 11 stated, nurses in the facility do not check her AV graft site. She added No they don't check it here. Nurses don't check it. During an interview on 7/1/2016 at 3:28 pm, Licensed Vocational Nurse (LVN) 5 stated, On 6/27/16 pm shift at 3 pm, I received report from LVN 1 that Resident 11's has change of condition for elevated INR of 4.3. She had [MEDICAL TREATMENT] that day and her left upper arm AV graft was bleeding after [MEDICAL TREATMENT]. During day shift bleeding went through the dressing and LVN 1 put pressure and notify the doctor. I'm not sure what time LVN 1 notified the doctor, she secured the site with more dressing. The bleeding continued during my shift. The (Certified Nursing Assistant) CNA notified me around 6:45 PM that Resident 11 was bleeding through the dressing. Resident 11 told the CNA that she's still bleeding. I checked it she has an ace wrap on the site. You can see the bleeding in front of the dressing and it drained at the bed sheet. But the whole ace wrap was not soiled with blood, not in front. I informed the doctor who happens to be here that time and he ordered to put a pressure for 45 minutes. I undid the ace wrap and I'm confused if I need to remove all the dressing behind. There was two ABD pads (Army Battle Dressing, used to manage heavy draining wounds or large wounds) completely soiled and underneath has tape and more dressings. I'm confused if I will take it off so I inform the doctor and he came in he take a look and said to remove everything. We saw a little prick and it keep on gushing and gushing so I put a pressure with dressing for 25 minutes and the CNA helped me. She took over for another 20 minutes or so, but it's getting soiled quickly. That time the doctor left so I called him that pressure was not working and he said, send her out. I informed the ambulance they said ETA (expected time of arrival) was 90 minutes or two hours. Then I got an approval for 911 instead and they came in, in three minutes. Review of the ED (emergency department) Transfer Summary, dated 6/27/16, indicated at 9:16 PM Bleeding from [MEDICAL TREATMENT] shunt in the left upper arm since 1100 (11 AM). Review of the NURSING HOME TRANSFER FORM, dated 6/28/16, indicated [MEDICAL TREATMENT] graft sutured - bleeding controlled. During an interview on 7/5/16 at 8:58 AM, the Medical Director stated, .That certain nurse that day (6/27/16 pm shift) doesn't know how to do pressure or pressure dressing . During an interview on 7/5/16 at 12:34 pm, LVN 1 stated, Resident 11 informed the CNA that she's bleeding from her AV graft site. The CNA informed me and I applied ABD pads with ace wrap (trademark for an elasticized wrap). According to LVN 1 there was no in-service or training on managing bleeding of [MEDICAL TREATMENT] site. LVN 1 stated, Training or in-service for [MEDICAL TREATMENT] site bleed, No I don't believe so. During an interview on 6/30/16 5:39 pm, Licensed Vocational Nurse (LVN) 2 explained the procedure in assessing the residents after [MEDICAL TREATMENT]. LVN 2 stated, We check the [MEDICAL TREATMENT] access after [MEDICAL TREATMENT]. I look for bleeding or check if it's intact. I never touch it, it always comes in with bandage after [MEDICAL TREATMENT] and I never take out any bandage yet. If there's bleeding, I will apply pressure. For documentation, we only document if there's changes. The frequency of documentation was based on the residents' healthcare coverage. On 7/5/16 at 8:30 am, the Surveyor requested a copy of staff training log or in-service record for responding to medical emergencies such as bleeding. There was no documentation presented. During interview on 7/5/16 at 2:50 PM, the Administrator stated, We don't have in-service for dealing with bleeding or change of condition because of bleeding. We will add it on in our future in-services. Review of Satellite Healthcare: LTCF (Long Term Care Facility) - [MEDICAL TREATMENT] ([MEDICAL CONDITION]) Compliance Agreement with a revision date of 6/28/13 no time indicated, .4. Education: Facility must educate its staff in the following areas to assure the Facility staff's ability to perform the following interventions .g. Management of emergencies and complications which include .bleeding/ hemorrhaging . Review of National Kidney Foundation: [MEDICAL TREATMENT] Access (retrieved from https://www.kidney.org/sites/default/files/11-50-0216_va.pdf on 7/12/16) indicated, .Bleeding From . Access: Warning Signs: Bleeding from a fistula or graft that lasts more than 20 minutes after .[MEDICAL TREATMENT] treatment is over .Steps to Take: For bleeding from a fistula or graft, gently press . access with a clean gauze pad to stop the blood; if bleeding lasts more than 20 minutes, call . doctor or [MEDICAL TREATMENT] center at once. 3. During review of Resident 11's [MEDICAL TREATMENT] Care Plan, dated 4/11/16, and a concurrent interview on 7/1/16 at 1:52 pm, the RDCO acknowledged there was no specific care intervention to manage emergencies such as bleeding. Review of facility policy titled LTC (long term care) Health Information Practice and Documentation Guidelines dated August 2001, indicated, .6.0.2 Purpose of the Documentation: . It must contain enough information to show that the facility knows the status of the individual has adequate plans of care and provides sufficient documentation of the effects provided. Documentation should provide a picture of the resident and their response to treatment, changes in condition and changes in treatment .

Based on interview, and record review, the facility failed to treat 5 out of 19 sampled residents (Resident 4, 11, 16, 18, and 19) with dignity when the facility failed to meet these Residents' requests for assistance in a timely manner. Failure to meet these residents' needs in a timely manner resulted in: 1. Resident 11 having to wait 40 minutes for his pain medication. 2. Residents 16 feeling frustrated and being trapped while he waited for toileting assistance. 3. Resident 4 feeling frustrated when he waited, after using the call light, about 30 to 40 minutes for assistance to reposition him in bed by the staff. 4. Resident 18 and 19 having to wait for at least 15 minutes for assistance after using their call lights. These deficient practices negatively impacted Residents 4, 11, 16,and 17; therefore constituted harm. For Resident 11, he was in pain and not treated in a dignified manner when staff were conducting shift change report instead of treating his pain. For Resident 16, there was emotional harm when he stated he felt like a prisoner in his own room. This was because staff failed to treat him with dignity by assisting him in a timely manner. Resident 16 stated, continual use of his call light elicited the same response of frustration and hopelessness because he was at the mercy of the staff, you don't know when (they'll come). For Resident 4, he stated he felt frustrated and a sense of hopelessness what else can I do? when staff were not assisting him in a timely manner. Findings: 1. Review of Resident 11's physician orders [REDACTED]. Resident 11 was prescribed the following pain medications to manage his pain: [MEDICATION NAME] (narcotic pain medication for moderate to severe pain) 2.5 mg (milligram) at bedtime, Tylenol 650 mg every four hours as needed for pain, Tylenol 650 mg every four hours for pain, [MEDICATION NAME] (narcotic pain medication for moderate to severe pain) 5 mg 30 minutes prior to physical therapy, [MEDICATION NAME] 2.5 mg every four hours as needed for mild to moderate pain, [MEDICATION NAME] 5 mg every four hours as needed for moderate pain, and [MEDICATION NAME] 10 mg every four hours as needed for severe pain. During an interview on 4/22/15 at 3:00 PM, Resident 11's Private Care Giver (PCG) stated . about 1 to 1.5 weeks ago around 3 o'clock in the afternoon, Resident 11 was in his room and said he was in pain. The PCG stated Resident 11 was moaning and saying oh my God.oh my God.I can't handle this anymore. The PCG stated she pushed Resident 11's call light and waited for assistance. Ten minutes later, when no staff showed up, the PCG went outside and found a staff. The PCG stated a staff told her the nurses were busy because it was shift change. Another 10-15 minutes later, when no one came, the PCG stated she went looking for help. The PCG stated she talked to a female in a white lab coat and the staff member said she would send a nurse. A staff came in 10 minutes later to assess Resident 11. The PCG was told staff were still busy because of shift change and that someone will be in to give Resident 11 his pain medication. Resident 11 had to wait another 10 minutes before his nurse finally came to give him his pain medication. The PCG stated this whole incident took a total of approximately 40 minutes before Resident 11 got his pain medication. During an interview on 4/24/15 at 2:30 PM, the DON stated her expectation was that if a resident was in pain during shift change, the nurse should stop the shift change report/endorsement and the nurse should assess the resident to see if pain medication should be administered. During an interview on 4/24/15 at 3:00 PM, Licensed Vocational Nurse (LVN) 1 stated if a patient was in pain during shift change, It's my responsibility to stop shift change (report/endorsement) and give pain medication. 2. Review of Resident 16's physician orders [REDACTED]. Review of Resident 16's Minimum Data Set (MDS) assessment, dated 4/1/15, indicated he was alert and oriented to person, place, and time, required extensive assistance of two staff with bed mobility, transfers, and toilet use. During an interview on 4/23/15 at 9:25 AM, Resident 16 stated it can take as long as 15 to 20 minutes for any staff to answer his call light. Resident 16 stated, that this morning, he rang his call light at 6:20 AM and it took until 6:40 AM before a staff member looked in on him to give him his urinal. Resident 16 stated he felt . frustrated.trapped in this room .having to hold in my urine.close to getting wet.there's nothing I can do.I'm at their mercy. Resident 16 stated this happens three to four times a week and he still has the same feelings now when he activates his call light because .you don't know when (they will come to help you).you are holding in your urine.the door is closed.(you are their) prisoner.they will come whenever they decide to come. 3. Resident 4 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Brief Mental Status examination score was 15 (cognitively intact). During an interview with Resident 4, on 04/23/15, at 9:15 AM, he stated Night shift staff was worse because when I call them for my needs, it takes them 30-40 minutes to come and respond, I feel frustrated. This happens many times, what else can I do? 4. During a group interview on 04/21/15, at 10:30 AM, Resident 18 and 19 expressed frustration on the length of time they need to wait for the nurse to respond to their needs by using their call lights. Resident 18 stated The staff were very busy at certain schedule, you have to wait for them about 10 to 15 minutes to respond. During an interview with DSD (Director of Staff Development) on 04/21/15, at 10:00 AM, she stated the facility staff tried their best to answer the residents' call light. The facility policy and procedure titled Call Light, Use of Procedure 230, indicated .6. Answer call lights in a prompt, calm, courteous manner.7. Never make the resident feel you are too busy to give assistance. Facility staff were not treating these residents with dignity when they failed to meet their needs in a timely manner. This failures resulted in sustained negative impact in Residents 4, and 16's psychological well-being. Resident 16 stated he now feels uncertainty when he activates his call light because he does not know when staff will come to help him. Resident 4 stated he has feelings of hopelessness when he said what else can I do? as he recalled how he waited for 30-40 minutes for staff to respond to his call light.