Every finding on record at Redlands Community Hospital D/P SNF

Based on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. Resident 4's Enhanced Barrier Precautions (EBP-an infection control guideline that requires staff to wear a gown and gloves while performing high-contact care activities with all residents who are at higher risk of acquiring or spreading infectious diseases) protocol were not followed in accordance with facility's policy and procedure (P&P). 2. One glucose monitoring (a device used to measure the amount of sugar (glucose) in the blood) device was found visibly soiled with dried white substance while docked (recharged) at the nurse's station. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 7 medically compromised residents and staff in the facility.Findings: 1. During a review of Resident 4's Record of Admission (contains demographic and medical information), undated, the Record of Admission indicated Resident 4 was admitted to the facility on [DATE]. A review of the Resident 4's History and Physical (H&P-contains information of health issues), dated November 3, 2025, indicated, Resident 4 was admitted with diagnoses which include intraparenchymal hemorrhage of brain (a brain bleed that occurs within the actual brain tissue.), dysphagia (swallowing difficulties), and hypertension (when the pressure in the hearts blood vessels is too high). During an observation on December 3, 2025, at 9:10 AM, outside Resident 4's room, an EBP sign was observed posted on the door. During an observation on December 3, 2025, at 9:15 AM, inside resident 4's room, observed Registered Nurse (RN)2 administering the following medications via Gastrostomy tube (G tube- a tube inserted through the belly that brings nutrition directly to the stomach.); rosuvastatin (used to lower high cholesterol) 20 milligrams (MG-a unit of measurement), sertraline (used to treat various mental health conditions) 25 MG, lisinopril (used to treat high blood pressure)10 MG, Acetaminophen 325 MG / Hydrocodone Bitartrate 10 MG,(used to manage moderate to severe pain) to Resident 4 on EBP without wearing the required protective gown. During a follow-up concurrent observation and interview and on December 3, 2025, at 1:30 PM, with RN 2, outside Resident 4's room, EBP signed was reviewed with RN2. EBP sign says gown is be worn with resident contract. RN 2 verified and confirmed Resident 4 is on EBP precaution. RN 2 confirmed that she did not wear any protective gown during her medication administration. RN 2 acknowledged that she did not follow the facility's P&P for EBP. During a concurrent interview and record review on December 3, 2025, at 1:44 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Enhanced Barrier Precaution, dated April 2025, was reviewed. The P&P indicated, .1. The use of gowns, gloves and masks by health care providers will be based on risk assessment criteria and the patient care activities whether or not the patient is known to be multi drug resistant organism (MDRO) colonized or infected.1. Risk assessment criteria to implement enhanced barrier precautions (EBP).a. iii. Presence of indwelling devices urinary catheter, feeding tubes.b . Patient care activities.b. viii. Device care or use (central line, urinary catheter, feeding tube and tracheotomy). The DON stated the policy was not followed and further state it is important for the P&P to be followed to prevention the spread of infectious diseases. 2. During a current observation and interview on December 3, 2025, at 6:23 AM, with RN 1, on the Transitional Care Unit (TCU) Nursing Station, a glucose monitoring was found visibly soiled with dried white substance docked at the nurse's station. RN 1 acknowledged the glucose monitor was dirty with a white substance, RN 1 stated the facility's expectation is for patient care equipment to be cleaned after use on each resident. During an interview on December 3, 2025, at 7:45 AM, with the DON and Infection Control Nurse (ICN), the DON and ICN stated that the facility's P&P for patient care equipment is to be cleaned prior and immediately after use for each resident. During a concurrent interview and record review on December 3, 2025, at 12:46 PM, with the DON, the facility's P&P titled, Guidelines for Care and Cleaning of Patient Equipment, dated April 2024, was reviewed. The P&P indicated, .2. To reduce the risk of transmission of microorganisms, and the spread of infection, by effective cleaning and decontamination. A. The following equipment and items are to be wiped with hospital approved disinfectant wipes in between each patient use by the person attending the patient.17. Blood glucose monitor. The DON confirmed that the P&P was not followed and stated that adherence is critical due to the increased infection risk within the resident population.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were properly labeled for one of three sampled residents (Resident 7) when the gastrostomy tube (G-Tube-a soft tube placed through the skin directly into the stomach) formula bottle (a bottle premixed medical nutrition formula used for tube feeding to provide calories, proteins and nutrients when a resident cannot eat by mouth is given by the stomach) was not labeled with nurse initials and the water flush bag (a water bag used to deliver scheduled water flushes though the feeding tube to maintain hydration and keep the tube clear) was not labeled with the prescribed rate as required. These failures placed Resident 7 at risk for receiving incorrect formula, improper feeding rates, or inadequate hydration, which potentially resulting in dehydration, electrolyte imbalance, aspiration (chocking), and compromise nutrition. Findings: During a review of Resident 7's Patient Demographics (contains patient background), Patient Demographics indicated, Resident 7, was admitted to the facility on [DATE]. During a review of Resident 7's History & Physical Report (H&P-contains medical information), the H&P indicated, Resident 7 was admitted to the facility on [DATE], with diagnoses of gastric cancer (a type of cancer that starts in the stomach), recent gastric / intestinal perforation repair (a surgery to fix a hole or tear in the intestine so that food and fluids do not leak) and gastroesophageal reflex disease (GERD-a condition where stomach acid flows back into the throat or esophagus) .Assessment Plan.Devices: PEG tube (percutaneous endoscopic gastrostomy-a soft feeding tube place through the skin into the stomach so the person can get nutrition). During a review of Resident 7's Nutrition Therapy Recommendations, dated November 21, 2025, at 1:15 PM, the Nutrition Therapy Recommendations indicated, Nutrition Related Concerns: Increase Nutrition Need, tube Feeding Type: [Brand Name], Tube Feeding Rate (mls [milliliter-unit measurement] / [per] hr [Hour]): 65 . During a review of Resident 7's Physician Order, dated November 20, 2025, the Physician Order indicated, Order, short bowel tube feeding, [Brand Name] 1 each PEG Q24 HR (every 24 hours) @ [at] 1400 [2:00 PM] (total formula ordered per 24 hours) liquid ., Dose, 65 ml/hr. During a review of Resident 7's Physician Order, dated December 2, 2025, at 9:32 AM, the Physician Order indicated, Order Free H20 (water) q4h (every 4 hours) ., Intervention Text Amount: 200 ml. During an observation on December 1, 2025, at 10:06 AM, in Resident 7's room, Resident 7 was observed lying in bed receiving continuous enteral tube feeding. Resident 7's feeding setup was reviewed, and the following were noted: a. The formula bottle was labeled with Resident 7's name, starting date and time, and the rate of formula. The nursing staff initial who started the formula was missing. b. The water flush bag was labeled with Resident 7's name, room number, and starting date and time. The prescribed water rate was missing. During an interview on December 1, 2025, at 10:10 AM, with Registered Nurse (RN 3), inside Resident 7's room, RN 3 stated the tube feeding labels must include: resident name, room number, formula type, rate, date, start time, and nurse initials. RN 3 confirmed that the formula bag was missing nurse initials, and the water flush bag was missing the prescribed rate. During an interview on December 1, 2025, at 4:05 PM, with the Clinical Nurse Educator (CNE), inside the conference room, the CNE stated that all formula bags and water flush bags must be labeled with patient information, date, time, rate, and nurse initials. During a concurrent interview and record review on December 2, 2025, at 11:11 AM, with the CNE, the facility's policy and procedure (P&P) titled, Nasal [Nose] /Oral [Mouth] Gastric tube, Insertion, Maintenance and Feeding Tube Use, dated April 2022, was reviewed. The P&P indicated, .h. Label the bag with patient information; enteral access type; and the tube feeding formula type, strength, and amount. Include the date and time and initial it. The CNE stated that the formula bag should have been initiated, and the water flush bag should have included the prescribed rate.

Based on observation, interview, and record review, the facility failed to post facility name, and the total number and the actual hours worked per shift for licensed and unlicensed staff daily. This failure resulted in residents, family, and staff being unable to see if the unit is staffed appropriately.Findings: During a concurrent observation, interview, and record review on December 3, 2025, at 5:51 AM in the Transitional Care Unit (TCU) with the Registered Nurse (RN 1), the in-unit staffing list (a posted list visible to residents, family, and staff, that outlines how many hours all patient care staff classifications are working during a given shift) was posted on a television monitor. The television did not show the facility's name, or the actual hours worked per shift for licensed and unlicensed staff. The RN 1 stated the Direct Hours Per Patient Day (DHPPD)(the average number of hours per day that nursing staff spend providing hands-on care to each resident in a facility) is not posted anywhere in the unit. During a concurrent interview and record review on December 4, 2025, at 7:50 AM, with the Director of Nursing (DON), the DON stated, The DHPPS is now posted on the unit but I only started calculating the DHPPD yesterday because I did not know we had to do it because this has never come up. The DON further stated the expectation was that the DHPPD should be posted daily so that residents, family, and staff know if the facility has appropriate staffing. During an interview on December 4, 2025, at 8:20 AM, with the DON, the DON stated, We do not have a policy for that, we just follow the regulations. The DON further stated the regulations were not followed.

Based on interview and record review, the facility failed to ensure the successful electronic submission of complete and accurate direct care staffing information was transmitted to Centers for Medicare and Medicaid Service (CMS) for two quarters (May 13, 2025, and August 14, 2025). This failure resulted in the facility not being monitored for any potential staffing issues.Findings: During an interview and record review on December 3, 2025, at 8:55 AM, with the Director of Nursing (DON), the CMS Submission Report (various mandatory reports such as payroll based journal (PBJ) or staffing data based on payroll) for the 2025 quarters were reviewed. The DON stated, The PBJ is supposed to be submitted quarterly. I thought it went through, but it did not due to issues with our system, [Name of Company]. The DON further stated, The PBJ Submission on May 13, 2025, and August 14, 2025, were submitted to CMS but our [Name of Company] we used erased the information because of the wrong code so it was transmitted with no staffing information. The DON further stated, It's important that information is transmitted to show we have enough staff to care for our residents. During an interview on December 4, 2025, at 8:18 AM, with the DON, the DON stated, We do not have a policy. We just follow the regulations.

Based on interview and record review, the facility failed to ensure the nursing staff provided treatment appropriately for one of seven sampled resident (Resident 18) when the nursing staff did not check Resident 18's blood glucose (sugar) daily as ordered. This failure resulted in Resident 18 inadequately monitored for blood sugar, which had the potential to cause uncontrolled blood sugar and negatively affect Resident 18's health and safety.Findings: During a review of Resident 18's admission Records (contains demographic and medical information), undated, Resident 18 was admitted to the facility on [DATE] with diagnoses that included malignant neoplasm of female breast (breast cancer, abnormal cells in the breast grow uncontrollably and form a tumor), metastatic cancer to the spine (cancer cells traveled from the breast and formed new tumors in spine bones), and diabetes mellitus type II (a condition where the body cannot control blood sugar). During an interview on December 1, 2025, at 10:21 AM, with Resident 18, Resident 18 stated, I am a Diabetic Type II, and I am not on insulin, but on oral medications to help with my blood sugar. During a review of Resident 18's MD [Medical Doctor] Orders, start date of November 27, 2025, the MD Orders indicated, Blood glucose monitoring every AM (morning). During a concurrent interview and record review on December 2, 2025, at 8:17 AM, with the Director of Nursing (DON), Resident 18's blood glucose lab values in her EMR (electronic medical record- a digital version of a patient's paper chart for a facility, containing their medical history, diagnoses, medications, and test results), dated from November 27, 2025, to December 1, 2025, was reviewed. The blood glucose was missing as follows: On November 30, 2025 On December 1, 2025 The DON verified and acknowledged the two missing blood glucose and stated it was important to check resident's blood glucose for patient safety and overall quality of care for residents. During a concurrent interview and record review on December 2, 2025, at 3:41 PM, with the DON, the following facility's policy and procedure (P&P) titled, Orders for Medication, Treatment and Diagnostic Testing, dated January 2025, was reviewed. The P&P indicated, To specify the conditions under which Hospital personnel may accept and carry out orders for the administration of medication, treatments, and diagnostic tests . The DON acknowledged the policy was not followed. The DON stated this policy is the only policy specific to following MD orders, and further stated the blood glucose should have been checked on the morning of November 30, 2025, and December 1, 2025, and was not.

Based on interview and record review, the facility failed to ensure the quarterly Resident Assessment Instrument/Minimum Data Set (RAI/MDS- a facility assessment and care planning process used by nursing home staff as required by the Centers of Medicare and Medicaid Services [CMS]) was completed and submitted to CMS in accordance with federal submission timeframes, for one of six reviewed for resident assessment (Resident 1). This failure resulted in inadequate monitoring of progress or decline for Resident 1 and the lack of resident specific information to CMS for payment and quality measure monitoring. Findings: During a review of Resident 1's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), the H&P indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus ( a disease that causes your blood sugar to be too high), end stage renal disease (ESRD - kidney failure) and osteomyelitis (an infection inside a bone) to the left foot. During a concurrent interview and record review on November 7, 2024, at 10:40 AM, with the MDS Nurse (MDSN), Resident 1's MDS assessment data was reviewed. The quarterly MDS assessment, that was due September 18, 2024, was not submitted (36 days past due). The MDSN stated, the MDS assessment was not completed and was not submitted because CMS was updating the system. The facility policy and procedure (P&P) was requested related to the MDS assessment. The MDSN stated, the facility does not have a policy regarding MDS assessments, and that the facility follows the MDS RAI manual. The MDSN agreed that the MDS assessment should have been submitted on October 2, 2024. During a review of CMS's Resident Assessment Instrument Version 2.0 Manual (RAI), the RAI indicated, Chapter 2 .Assuming the resident does not have any significant changes in status or is not discharged from the facility, the next assessment in the [MDS] assessment schedule is the Quarterly assessment. The Quarterly assessment is to be completed within 92 days of the R2b (signed completion) date of the Admission assessment. The [MDS] schedule would continue with another Quarterly assessment to be completed within 92 days of the R2b of the previous Quarterly . During a review of facility Job Description (JD) titled, MDS Coordinator/DSD, RN, dated July 1, 2024, was reviewed. The JD indicated, .Position Specific Responsibilities .Resident Assessment .Conducts and coordinates the development and completion of the resident assessment (MDS) in a timely manner in accordance with current rules, regulations and guidelines .Assigns assessment reference date and starts the schedule of assessments for all residents with the interdisciplinary team .

Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity in an environment that enhances quality of life for two of five sampled residents (Residents 55 and 56) when lunch was served in a plastic bag with disposable plastic container and utensils and no placemat, tray or plate were provided. This failure resulted in Residents 55 and 56 not having a place to set their food when eating and having to place some items on the table when preparing their meal to eat which had the potential to negatively impact the residents' mental and psycho-social well-being. Findings: 1a. During a review of Resident 55's History and Physical (H&P-contains resident's medical history, physical examination and reason for admission to the facility), the H&P indicated, Resident 55 was admitted on [DATE], for physical therapy (PT-a treatment method where physical methods as massage, heat treatment and exercise are used rather than by drugs or surgery) and occupational therapy (OT-a treatment method where daily life activities are performed) after sustaining a right humerus (bone in the upper arm) fracture (broken bone). During a concurrent observation and interview on November 5, 2024, at 12:12 PM, in Resident 55's room, Certified Nurse Assistant (CNA) delivered Resident 55's lunch in a plastic bag, there was no placemat, tray or plate provided. The plastic lunch bag included the sandwich Resident 55 ordered, served in a plastic clam container (small container that can only accommodate a sandwich) cut in half and stacked. Packets of condiments (mustard and mayonnaise) provided along with a bag of plastic utensils. Resident 55 stated, she had not received any of her meals on a plate or tray since being admitted . Resident 55 further stated, meals were provided similar to how you would get takeout. During a concurrent observation and interview on November 6, 2024, at 8:53 AM, in Resident 55's room, Resident 55 was sitting in her chair finishing up breakfast which was served on a plate with a tray. Resident 55 stated, she was surprised when her breakfast was served on a plate with metal utensils as this was the first time, she had received her meal this way and wanted to know what the surveyor did to get this kind of service. Resident 55 further stated, it was nice to have a plate with metal utensils and room to eat because it was challenging with her previous meals since she can not use her right arm because of the fracture. Resident 55 stated, having a space to eat and a sturdy plate and utensils made her breakfast better. 1b. During a review of Resident 56's H&P, the H&P indicated, Resident 56 was admitted on [DATE], for PT and OT after sustaining a left hip fracture. During an interview on November 5, 2024, at 12:10 PM, with the Director of Dietary Services (DDS), the DDS stated, residents will receive a plastic bag with disposable food container or clam shell and disposable utensils if they are on any type of isolation precautions (barriers that help prevent the spread of germs). The DDS stated, if a patient has an order for precautions at 0600 AM they will receive all food on disposable items so that no contaminated items return to the cafeteria, it has been this way since pandemic. The DDS further stated, if there is an order to remove a resident from isolation precautions placed after 6:00 AM, food service will continue on disposable items for that day. During a concurrent observation and interview on November 5, 2024, at 12:20 PM, in the dining room, CNA delivered Resident 56's lunch in a plastic bag, there was no placemat, tray or plate provided. Resident 56's sandwich was served in a small clam shell container and packets of condiments were provided along with a paper bag of plastic utensils. Resident 56 prepared her sandwich with condiments which required stacking the lettuce and onion on the corner of the container, with the lettuce making contact with the surface of the table. Resident 56 stated, most meals come served this way, or in a foam container with disposable utensils and cups. During a concurrent interview and record review on November 7, 2024, at 9:57 AM, with the Director of Skilled Nursing (DSN) and Nurse M anager (NM), Resident 55's and 56's Order Summary dated November 5, 2024, was reviewed. The NM stated, there was no documented evidence Resident 55 and 56 had an order for isolation precautions since admission. The NM could not explain why these two resident's lunches were served in a plastic bag. During review of the facility policy and procedure (P&P) titled, Resident Rights dated May 2024, the P&P indicated, .A. Dignity: the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect .E. Accommodation of Needs: A resident has the right to 1. Reside and receive services in the facility with reasonable accommodation of individual needs and preferences .H. Environment: 1. A safe, clean, comfortable, and homelike environment .

Based on observation, interview and record review, the facility failed to follow policy and procedure (P&P) for four of five residents when: 1. Staff failed to perform hand hygiene during medication administration and having direct contact with three residents (Resident 55, 56, and 106). 2. Intravenous (IV-into the vein) tubing was not used according to standards of practice for one resident (Resident 57) when the facilities policy and procedure (P&P) for IV therapy was not updated. These failures had the potential to place patients at a greater risk for spreading of infection from cross-contamination (the transfer of harmful bacteria) causing a preventable bloodstream infection, and negatively impact residents' health and safety. Findings: 1a. During a review of Resident 106's Admitting Form (a demographic data about the resident), the Admitting Form indicated, Resident 106 was admitted to the facility on [DATE], for physical therapy (PT-a treatment method where physical methods as massage, heat treatment and exercise are used rather than by drugs or surgery) and occupational therapy (OT-a treatment method where daily life activities are performed). During an observation on November 6, 2024, at 8:48 AM, Licensed Vocational Nurse 1 (LVN 1) was observed leaving Resident 106's room without hand washing. LVN 1 went to the Omnicell (a medication dispensing system) and got Norco (a combination of hydrocodone and acetaminophen to treat pain) 7.5 milligrams (mg-unit dosing medication) and 325 mg. LVN 1 came back to Resident 106's room and administered Norco to Resident 106 without hand washing and sanitizing (kill germ) the medication cart. 1b. During a review of Resident 55's History and Physical (H&P -contains resident's medical history, physical examination and reason for admission to the facility), the H&P indicated, Resident 55 was admitted on [DATE], for PT and OT after sustaining a right humerus (bone in the upper arm) fracture (broken bone). During an observation on November 6, 2024, at 8:57 AM, in Patient 55's room, LVN 1 left Patient 55's room to get a pain medication from the Omnicell. LVN 1 did not perform hand washing or hand sanitizing upon returning to the room with the pain medication and did not perform hand hygiene before giving Patient 55 her medication. 1c. During a review of Resident 56's H&P, the H&P indicated, Resident 56 was admitted on [DATE], for PT and OT after sustaining a left hip fracture. During an observation on November 6, 2024, at 9:07 AM, after exiting Patient 55's room, LVN 1 entered Patient 56's room without performing hand washing or hand sanitizing. Hand hygiene was not performed by LVN 1 prior to administering Patient 56's medication. During an interview on November 6, 2024, at 9:11 AM, with LVN 1, LVN 1 stated, she washes her hands when entering a resident's room and there is no need for washing or sanitizing her hand after she gets her medicines from the Omnicell. LVN 1 further stated, hand hygiene needed to be performed in-between each patient when performing patient care. During an interview on November 8, 2024, at 9:20 AM, with the Infection Preventionist Nurse (IPN), The IPN stated, staff are expected to wash hands after administering medication and after each resident care. The IPN further stated, staff should also wash hands after touching any objects and before caring for residents to prevent the spread of infection. During a concurrent interview and record review on November 8, 2024, at 9:30 AM, with the Director Skilled Nursing (DSN), the facility's policy and procedure (P&P) titled, Medication Administration Using Electronic Medication Administration Record (e MAR)/BMV and Infection Control, dated April 23, 2024, was reviewed. The P&P indicated, PURPOSE 1. To prevent contamination and spread of microorganism. PROCEDURE A. Five key areas to be disinfected after each patient use :1. Keyboard 2. Mouse 3. Screen 4. Scanner 5. Countertop/Handle B. Standard Precautions for all patient.1. Wash your hands or sanitize with alcoholic gel .5. dispose of trash and wash or sanitize the hands. 6. Put on the gloves and wipe the five key areas of the cart with the hospital approved disinfectant.7. Wash your hands or sanitize with alcohol gel . The DSN stated, as you have the direct observation with the staff, staff is supposed to wash her hands as per policy, so policy was not followed. During a concurrent interview and record review on November 8, 2024, at 9:32 AM, with the DSN, the facility's policy and procedure P&P titled, Hand Hygiene, dated April 23, 2024, was reviewed. The P&P indicated, PURPOSE 1. Hand hygiene reduces the risk of infection from patient to patient and from patient to health care provider .3. Hand Hygiene minimizes counts of both transient and resident skin flora. 4. Hand Hygiene is generally considered the single most important procedure for preventing hospital acquired infections . The DSN stated, staff is expected to wash hands to prevent spread of infection. 2. During a review of Resident 57's H&P, the H&P indicated, Resident 57 was admitted on [DATE], for an infected left knee and continued intravenous antibiotic (medication used to treat an infection) with PT and OT. During an observation on November 5, 2024, at 9:59 AM, in Patient 57's room, Ceftriaxone (an antibiotic) 2 Grams (gm - unit of measurement) was hanging from the IV pole with the IV tubing dated November 2, 2024. The IV was not connected to Patient 57, the end of the IV tubing was circled around on self and connected to the IV tubing's medication port. There was no cap noted to the end of the IV. During a concurrent interview and record review on November 5, 2024, at 11:30 AM, with the DSN and Nurse Manager 2 (NM2), the facility's P&P titled, Intravenous Administration, dated October 2024, was reviewed. The P&P indicated, .3. Aseptic technique/standard precautions will be used in all IV insertion and maintenance .13. Tubing will be changed every 96 hours or PRN (as needed) . The NM2 stated, IV tubing needs to be replaced every 96 hours per the policy and does not differentiate between how the tubing is used, such as intermittent (tubing that is disconnected after infusion and reconnected for the next dose). The DSN stated, there was no mention of how to cap the IV tubing during intermittent IV medication administration in the facility policy. The DSN further stated, the staff will loop around the end of the tubing and secure to the medication port between doses, this practice is not included in the P&P. The DSN stated, the facility does not have sterile caps for intermittent IV tubing. During a concurrent interview and record review on November 8, 2024, at 10:00 AM, with the IPN, the facility's P&P titled Intravenous Administration, dated October 2024, was reviewed. The P&P referenced Infusion Nurses Society Standard as the resource for this P&P. The current Infusion Nurses Society Standard dated January/February 2024 indicated, .standards of practice . intermittent IV tubing should be changed every 24 hours . If the tubing is to be reused within 24 hours, it should be covered with a sterile covering device . The IPN stated, the facility Intravenous Administration P&P was not updated with the current stands of practice per the reference cited in the P&P. The IPN further stated, the purpose of updating P&P's to current standards of practice is to prevent infection. 47394

Based on observation, interview, and record review the facility failed to maintain a sanitary kitchen in accordance with professional standards for food safety when: 1. In the kitchen entrance, there was no available hair restraints (such as hair nets and beard restraints) for kitchen staff and visitors to use. 2. Three kitchen staff, who had beards, were not wearing beard restraints while working inside the kitchen. These failures had the potential to cause foodborne illnesses to 8 medically compromised residents who receive food served by the kitchen. Findings: During a concurrent observation and interview, on November 13, 2023, at 8:29 AM, with the Kitchen Manager (Manager 1), the kitchen entrance was inspected. There was no available hair nets and beard restraints for staff and visitors to use upon entering the kitchen. The Manager 1 acknowledged the findings, and stated hair nets and beard restraints should be easily accessible near the kitchen entrance door. During a concurrent observation and interview, on November 13, 2023, at 9:20 AM, with the Associate Chef (Chef 1), in the kitchen, by the food preparation area, Chef 1 was observed to have a beard. He was not wearing a beard restraint. He stated that he doesn't need to wear a beard restraint since his beard was short. Chef 1 stated he was responsible for overseeing the food preparation for the cafe and tray line (a system of food preparation in which trays move along an assembly line). During a concurrent observation and interview, on November 13, 2023, at 9:56 AM, with the Kitchen Storekeeper (SK 1), in the kitchen, by the storage area, SK 1 was observed to have a beard and was not wearing a beard restraint. SK 1 stated the facility policy requires the kitchen staff to wear a beard restraint to conceal their facial hair. He stated that although he used to keep his beard trimmed, it has currently grown longer, resulting in a violation of the policy. During a concurrent observation and interview, on November 13, 2023, at 10:02 AM, with the Chef (Chef 2), in the kitchen, by the food preparation area, Chef 2 was observed to have a beard. He was not wearing a beard restraint. Chef 2 stated his beard was less than a quarter inch long, so he didn't need to wear a beard restraint. However, when asked how he determined the length of his beard, he admitted that he didn't know. Chef 2 stated his responsibilities included creating menus, managing the kitchen, and overseeing catering and cafeteria operations. During a concurrent observation and interview, on November 13, 2023, at 10:14 AM, with Manager 1, in the kitchen, by the food preparation area, Manager 1 acknowledged the kitchen staff who have beards were not wearing beard restraints. Manager 1 was asked to provide a policy regarding beard restraints, and she stated the facility has a policy for hair, but no policy specific to beards. She stated that she was aware of the Food and Drug Administration (FDA) regulation concerning the restraint policy for hair, beards, and body hair. A review of the facility Food and Nutrition Services, Policy Number: 1101, dated September 1994, indicated, .2. All vendors, staff, etc. are required to wear a hospital approved hat or hair net in the kitchen. Exception: hair net is not required when the head is devoid of hair. During a review of the 2023 Food Code, U.S. (United States) FDA dated 2023, the Food Code indicated, 2-402.11 (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair.

Based on observation, interview, and record review, the facility failed to follow proper sanitation and food safety practices to prevent foodborne illnesses when wet trays were stacked and stored together in the kitchen. This failure had the potential to promote bacterial growth that could lead to foodborne illnesses for a medically compromised population of seven out of seven residents who received nutrition from the facility's kitchen. Findings: During a concurrent observation and interview, with the Director of Food and Nutrition (DFN) on October 10, 2022, at 12:15 PM, 12 half-size pans and eight (8) full-size pans (pans- cooking utensils that are built with a flat bottom and raised sides to hold or prepare food ingredients. Two half pans can fill the same space as one full-size pan) were stacked wet on top of each other on a shelf. The DFN stated, those pans were washed and cleansed and further stated the pans are usually air-dried after washing then stored. The DFN stated, the pans shouldn't be stacked together wet because this can promote bacterial growth. During an interview and record review, with the [NAME] President of Professional and General Services (VP), on October 13, 2022, at 2:31 PM, facility's policy and procedure (P&P), titled, Food and Nutrition Services, dated October 2022, indicated, Subject: Ware Washing Procedure .Guidelines: Dishware could be washed manually or by utilizing a dish washing machine .5. Air dry the dishware. The VP stated, the facility did not follow their P&P. In a review of the FDA Federal Food Code 2017, 4-901.11 titled, Equipment and Utensils, Air Drying Required, the Food Code indicated, Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow.

Based on interview and record review, the facility failed to complete [FACILITY NAME] Notice of Medicare Non-Coverage (a form that contains information regarding the end date of Medicare covered services) for one of three (3) sampled residents (Resident 1). This failure had the potential for the resident to be uninformed regarding his/her specific rights and protections related to financial liability for potential incurred medical expenses as well as the right to appeal. Findings: During a review of Resident 1's clinical record titled, Admitting Form (contains the resident's demographics), the document indicated, Resident 1 was admitted to the facility on [DATE], due to needed medical treatments for a left foot infection (invasion and multiplication of bacteria, viruses, and/or parasites that are not normally present within the body). Resident 1 was discharged from the facility to home on June 23, 2022. During a review of Resident 1's clinical record titled, [HOSPITAL NAME] PDOC Progress Notes (Physician Documentation) , dated June 23, 2022, at 1:52 PM, by Physician 1, indicated, Resident 1 was scheduled to be discharged home and continue antibiotics at home for one week. During a review of the Facility's document titled, [FACILITY NAME] Notice of Medicare Non-Coverage, undated, indicated, The Effective Date Coverage of Your Current Transitional Care Unit Services Will End: ______. Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current {insert type} services after the effective date indicated above. You may have to pay for any services you receive after the above date. Your Right to Appeal This Decision-You have the right to an immediate, independent medical review (appeal) of the decision to end Medicare coverage of these services. Your services will continue during the appeal . During an interview with the DON on October 13, 2022, at 9:00 AM, the DON stated, the [FACILITY NAME] Notice of Medicare Non-Coverage form was not provided to Resident 1 due to the process being overlooked. During an interview on October 13, 2022, at 9:08 AM, with the Care Manager (CM), stated, the process of discharging a resident from Facility is, the CM communicates with the Physician and determines when the resident is ready for discharge. Once the decision has been made for the discharge, the CM calls the business office, and the Medicare discharge forms are provided to the resident 48 hours prior to discharge. During a joint concurrent interview and record review of the facility's Policy and Procedure (P&P) with the DON and the CM, on October 13, 2022, at 9:10 AM, [FACILITY NAME] Patient Care Policy Subject: Medicare Appeal Rights, dated October 14, 2019, was reviewed. [FACILITY NAME] Patient Care Policy Subject: Medicare Appeal Rights indicated, Policy: It is the policy of [FACILITY NAME] to issue the Important Message for Medicare ([NAME]), to explain the Message to patients and/or designees, and to have the patients and/or designees sign indicating their understanding of their discharge rights. This message must be delivered and explained upon admission and no more than forty eight (48) hours prior to discharge. The DON and CM concurrently acknowledged that the Facility P&P was not followed. During a concurrent interview and Job Description (JD) review with the DON on October 13, 2022, at 1:32 PM, Facility 's document titled, Assessment Template Preview: Assessment Name: Care Manager (2021-07): [FACILITY NAME], dated July 7, 2021, was reviewed. Assessment Template Preview: Assessment Name: Care Manager (2021-07): [FACILITY NAME], indicated, . The purpose of the Care Manager position is to support the physician . in facilitating patient care, the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction . The role integrates and coordinates utilization management, care facilitation and discharge planning functions. The Care Manager is accountable to a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization or resources. The DON acknowledged the CM did not fulfill the job description when Resident 1 was not provided the [FACILITY NAME] Notice of Medicare Non-Coverage form.

Based on interview and record review, the facility failed to ensure the Pharmacy Consultant (PC- provides expert clinical guidance to healthcare providers on the appropriate use of medication) completed a monthly Drug Regimen Review (DRR- a review of all medications a resident is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy) for two out of nine months reviewed. This failure had the potential to cause adverse consequences which may result from or be associated with medications that could jeopardize the health and safety of the vulnerable population from an universe of seven residents. Findings: During an interview with the Director of Nursing (DON) on October 12, 2022, at 8:45 AM, the DON stated, the facility conducts monthly drug regimen reviews for the residents. During a concurrent interview and record review with the PC, on October 12, 2022, at 10:40 AM, of the facility's Consultant Pharmacist's Monthly Drug Regimen Review, was reviewed. Facility's Consultant Pharmacist's Monthly Drug Regimen Review indicated, there were missing monthly DRR for the months of March 2022 and September 2022. The PC stated, March 2022 was missed due to scheduling conflicts, and September 2022 was missed because he was sick. The PC stated, the drug regimen review for both months should have been completed. During a review of the facility's policy and procedure (P&P), titled, Pharmacy Services, dated April 2022, indicated, Guideline: .B. The consultant pharmacist will: .1. Review the drug regime (sic) of each resident in the unit once a month and report any irregularities in writing to the Nurse Manager/DON and individual resident's physician when appropriate .

Based on observation, interview, and record review, the facility failed to observe infection prevention and control measures when: 1. A Registered Nurse 1 (RN 1) did not perform hand hygiene before wearing gloves and administering eye drop medication to Resident 60. This had the potential to cause contamination of medication and/or transmission of harmful germs related to health care-associated infections. 2. The Food Service Worker (FSW) failed to observe that personal food items shall not be stored at work stations. This had the potential to cause cross-contamination of food that can cause foodborne illness. Findings: 1. During a review of Resident 60's clinical document titled, Admitting Form (a document that contains the resident's demographic information), indicated Resident 60 was admitted on [DATE]. During a record review of Resident 60's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a concurrent observation and interview with the RN 1, on October 11, 2022, at 8:51 AM, RN 1 was observed wearing gloves while administering a medication patch on the back of Resident 60. RN 1 removed the gloves after administering the patch, then wore a new set of gloves without observing hand hygiene, then administered the eye medication [MEDICATION(S)] to Resident 60. RN 1 was asked about the facility's policy and procedure regarding donning (putting or wearing) off and on of gloves, RN 1 stated, they are expected to observe hand hygiene after removing gloves and before putting on new gloves. RN 1 further stated, he should have performed hand hygiene between every glove change and prior to administering the eye medication. During a record review of the facility's policy and procedure (P&P), titled, Patient Care, approved October 10, 2019, indicated, Subject: Hand Hygiene .Policy: A. Indications for Hand Hygiene .3. Before and after direct contact with patients, blood/body fluids or equipment and environmental items that is likely to be contaminated .6. After donning gloves and after removing gloves . 2. During a tour of the facility's kitchen with the Director of Food and Nutrition (DFN), on October 10, 2022, at 12:10 PM, observed three individually wrapped sweet bread on top of a shelf above the dishwashing sink. The DFN asked the FSW to remove it from the kitchen work station. During an interview with the FSW on October 11, 2022, at 12:03 PM, the FSW confirmed the three individually wrapped sweet breads were his personal food. The FSW stated, the facility has a locker room where they can place their personal belongings, and a refrigerator dedicated for staff use. The FSW further stated, personal food should not be kept in the work area inside the kitchen. During a concurrent interview and record review, with the [NAME] President for Professional and General Services (VP) on October 13, 2022, at 2:31 PM, facility's policy and procedure (P&P), titled, Food and Nutrition Services, effective October 2022, was reviewed. The P&P indicated, Subject: Personal Food at Work Stations. Purpose: To ensure that the risks associated with cross-contamination are minimized .Guidelines: 2. Personal food items shall not be stored at work station . The VP stated, the facility did not follow their P&P.

Based on observation, interview, and record review, the facility failed to implement their policy and procedure on infection control when: 1. An opened bottle was stored in the medication cart. The opened bottle was not labeled to indicate the contents of the bottle and was available for use; 2. A rapid rhino device (a device to stop nose bleeds) was available for use after the manufacturer's expiration date; 3. For Resident 58, an alcohol pad was used to clean the index (also known as the pointer or first) finger for blood glucose (sugar) testing and the same alcohol pad was used to stop the bleeding; These failures had the potential to expose the facility's residents to an increased risk of infection and adversely affect the health and safety of the facility's residents. Findings: 1. During an observation with the Registered Nurse (RN 2), on (MONTH) 28, 2019, at 2:40 PM, a white opened bottle was stored in the medication cart. During an interview with RN 2 on (MONTH) 28, 2019, at 2:43 PM, RN 2 stated the opened bottle contained lotion. She further stated there was no label to indicate the contents of the bottle. RN 2 stated the bottle was not labeled with a resident's name and she did not know how long the bottle had been open. RN 2 stated the unlabeled bottle should not have been stored in the medication cart. A review of the facility policy and procedure titled Infection Prevention Program/Plan dated (MONTH) (YEAR), indicated Purpose: 1. The purpose of the Infection Prevention Program is to identify infections, as well as prevent the risk of disease acquisition (sample) and transmission (spread) through the introductions of preventative measures. 2. During an observation with RN 2, on (MONTH) 28, 2019, at 2:45 PM, a rapid rhino device was stored in the medication cart. The rapid rhino device was available for use and had a manufacture's expiration date of (MONTH) 30, (YEAR). During an interview with RN 2, on (MONTH) 28, 2019, at 2:46 PM, RN 2 stated the expired rapid rhino device should not have been stored in the medication cart and should have been discarded in accordance with the manufacturer's guidelines on or before (MONTH) 30, (YEAR). A review of the facility's policy and procedure titled, Expired Goods Policy undated, indicated: Procedure: Inventory items that expire will be removed from inventory. Expired items and potentially usable damaged items will be place in a holding area for disposal. 3. A clinical record review of Resident 58's history and physical date (MONTH) 21, 2019, indicated Resident 58 was admitted on (MONTH) 21, 2019 with [DIAGNOSES REDACTED]. During an observation on (MONTH) 28, 2019, at 4:40 PM, RN 3 cleaned Resident 58's right index finger with an alcohol pad. RN 3 performed a finger stick with a lancet (a small sterile disposable needle) to test Resident 58's blood sugar level. After RN 3 had taken the blood sample, she used the same alcohol pad to apply pressure on the open site to stop the bleeding. During an interview with RN 3, on (MONTH) 28, 2019, at 4:50 PM, RN 3 stated the alcohol pad used to clean Resident 58's finger should have been discarded. RN 3 further stated she should have used a clean cotton ball to apply pressure on the site to stop the bleeding. During an interview with the Nurse Manager (NM), on (MONTH) 30, 2019, at 3:30 PM, the NM stated RN 3 should have applied a clean cotton ball or gauze pad to the site of the finger stick and applied pressure until the bleeding had stopped. A review of the facility policy and procedure titled Whole Blood Glucose Testing dated (MONTH) (YEAR), indicated 5. Procedure-Patient Test: C. Prep the patient's (resident's) finger with alcohol and allow to dry thoroughly. N. Apply pressure to the site of the finger stick with a cotton ball or gauze.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure on pain management when the comprehensive person-centered care plan and resident's goals did not meet the needs for one of five sampled residents (Resident 107). This failure resulted in persistent pain and anxiety for Resident 107. Findings A review of the clinical record for Resident 107, a document titled History and Physical indicated Resident 107 was admitted on (MONTH) 26, 2019, with [DIAGNOSES REDACTED]. During an observation on (MONTH) 28, 2019, at 11:30 AM, Resident 107 was observed lying in bed receiving oxygen through a nasal cannula (device that delivers oxygen through the nose). The oxygen flow meter (device that supplies continuous flow of oxygen through a tube) was set at 2 liters a minute (2LPM-unit of measurement). During an observation and interview with Resident 107, on (MONTH) 28, 2019, at 1:06 PM, Resident 107 was observed lying in bed in a supine position (on the back) watching television. Resident 107 stated she was not asleep at 11:30 AM. Resident 107 stated she had recently experienced a hearing loss in the right ear and when she is positioned in a left lying position, It is hard to hear the staff. Resident 107 stated she was in a lot of pain and could not sleep. A review of Resident 107's care plan initiated on (MONTH) 26, 2019, indicated Problem: Pain S/P (status [REDACTED]. Plan: Assess for pain QS (every shift) and PRN (as needed). Medicate for pain as ordered, reevaluate effectiveness of pain MEDs (medications) and side effects. Offer non pharmacological interventions for pain such as repositioning, cooling therapy. A review of the Medication Administration Record [REDACTED] 1. (MONTH) 26, 2019, at 6:51 PM, Dose: 2 tablets by mouth 2. (MONTH) 26, 2019, at 10:56 PM, Dose: 2 tablets by mouth 3. (MONTH) 27, 2019, at 4:36 AM, Dose: 2 tablets by mouth 4. (MONTH) 27, 2019, at 8:52 AM, Dose: 2 tablets by mouth 5. (MONTH) 27, 2019, at 1:04 PM, Dose: 2 tablets by mouth 6. (MONTH) 27, 2019, at 5:22 PM, Dose: 2 tablets by mouth 7. (MONTH) 27, 2019, at 10:10 PM, Dose: 2 tablets by mouth 8. (MONTH) 28, 2019, at 6:26 AM, Dose: 2 tablets by mouth 9. (MONTH) 28, 2019, at 2:43 PM, Dose: 2 tablets by mouth 10. (MONTH) 28, 2019, at 6:44 PM, Dose: 2 tablets by mouth 11. (MONTH) 28, 2019, at 11:10 PM, Dose: 2 tablets by mouth 12. (MONTH) 28, 2019, at 6:51 PM, Dose: 2 tablets by mouth 13. (MONTH) 29, 2019, at 8:35 AM, Dose: 2 tablets by mouth 14. (MONTH) 29, 2019, at 12:27 PM, Dose: 2 tablets by mouth 15. (MONTH) 29, 2019, at 17:41 PM, Dose: 2 tablets by mouth 16. (MONTH) 29, 2019, at 23:23 PM, Dose: 2 tablets by mouth During a medication pass observation and interview with the Licensed Vocational Nurse (LVN 1), on (MONTH) 29, (YEAR), at 12:27 PM, LVN 1 stated Resident 107 had been in a lot of pain. LVN 1 described Resident 107's pain as persistent. During an interview with Resident 107, on (MONTH) 29, 2019, at 1:45 PM, Resident 107 stated she had been on the same pain management regime since (MONTH) 21, 2019, with little to no relief from pain. Resident 107 stated the pain interrupts her sleep and she has been extremely tired due to the lack of sleep. Resident 107 stated she had informed the facility that she was not able to sleep and a sleeping pill had been added to her medication regime. Resident 107 stated the sleeping pill did not take the pain away and further stated her sleep continues to be interrupted by the pain. Resident 107 stated when she had asked for the PRN pain medication she had been told it was too early to receive another dose of pain medication. Resident 107 stated her home medication regime included [MEDICATION NAME] (pain medication for chronic moderate to severe pain which is an extended-release tablet used for around-the-clock treatment of [REDACTED]. A review of the physician's History and Physical for Resident 107, Resident 107 has a hx (history) of [MEDICAL CONDITIONS] end Stage ([MEDICAL CONDITION] stages of Progression [MEDICAL CONDITION] Stage 1 (early stage [MEDICAL CONDITION]), [MEDICAL CONDITION] Stage 2 (moderately progressed [MEDICAL CONDITION]), [MEDICAL CONDITION] Stage 3 (severely progressed [MEDICAL CONDITION]), [MEDICAL CONDITION] Stage 4 (very severely progressed [MEDICAL CONDITION]) indicating Resident 107 was in stage 4 of the disease. The physician further indicated Resident 107 had multiple falls with [MEDICAL CONDITIONS] (higher than normal Potassium in the blood- a chemical that is critical to the function of nerve and muscle cells, including the heart with acute [MEDICAL CONDITION] (kidney damage), Resident 107 has chronic pain. Resident 1 was admitted for further care . During an interview with the Pharmacist (PharmD 1) on (MONTH) 29, 2019, at 3:30 PM, PharmD 1 stated he had reviewed the clinical record for Resident 107 and stated the pain medication regime was appropriate to manage Resident 107's pain. ParmD 1 stated if the pain was not managed effectively, the pharmacist or the nurse would notify the physician for further guidance. During an interview with the Patient Safety Supervisor (PSS) on (MONTH) 29, 2019, at 3:40 PM, the PSS stated the pain management program was effective and the licensed nurse could administer pain medication using range orders under the facility's policy. The PSS stated when the licensed nurse administers the pain medication, the nurse determines the appropriate dose of medication for the resident from the previous responses to the dose. The PSS stated the Registered Nurse (RN) and the Licensed Vocational Nurse (LVN) are expected to use range orders. The PSS further stated she had not researched the scope of practice for LVNs and did not know if range orders were in the scope of practice for LVNs in California. The PSS stated the physician should be notified when a resident continues to have pain or show no improvement. During an interview with the Director of Pharmacy (PharmD 2) on (MONTH) 29, 2019, at 4:15 PM, PharmD 2 stated the pain medication is a safe dose and he was not aware the resident had experienced break-through pain (pain medicine that wears off before the next dose is due). PharmD 2 stated the physician should have been notified and the pain medication regime should have been re-evaluated to meet the need of the resident. During an interview with the Medical Director (MD 1) on (MONTH) 29, 2019, at 4:20 PM, MD 1 stated the expectation is the physician is notified when a resident's pain has not been managed effectively or when a resident experiences an adverse reaction to the pain medication regime. MD 1 stated the facility has a responsibility to ensure residents are managed property. During an interview with the Nurse Manager (NM), on (MONTH) 30, 2019, at 8:26 AM, the NM stated she had reviewed the clinical record for Resident 107 and the Register Nurse had not reconciled Resident 107's home medication regime. She stated Resident 107's acute pain was addressed but the chronic pain had not been addressed in the care plan. The NM stated more education is needed for the reconciliation of residents' home medication regime. The NM further stated Resident 107 should have been referred to the facility's pain management team for evaluation. During an interview with Resident 107 on (MONTH) 30, 2019, at 9:45 AM, Resident 107 stated the facility had changed the pain medication regime. Resident 107 further stated she had slept much better through the night. During an interview with the Nurse Manager (NM), on (MONTH) 31, 2019, at 3:26 PM, the NM stated the RN had documented Resident 107's chronic pain and home medication regime on the Head to Toe Assessment document. The NM stated responses entered on the Admission Assessment and Head to Toe Assessment indicate problems that should be addressed in the development of the plan of care. The NM further stated she did not know why the RN did not include the chronic pain findings in the plan of care for Resident 107. A review of the facility's policy and procedure with the Nurse Manager (NM), a document titled Documentation, Patient Care revised (MONTH) (YEAR), indicated: Policy: 7. The admission assessment interventions will be completed by a Registered Nurse (RN). The RN will document a Head to Toe Assessment every shift or as defined by unit policy. A review of the facility's policy and procedure titled Pain Assessment and Management revised (MONTH) (YEAR), indicated: Purpose: To provide the clinical staff with guidelines to provide safe and effective pain management to a level that is acceptable to the patient while facilitating healing, promoting comfort, increasing mobility, and promoting rest. A review of the Registered Nurse (RN) job description, undated, a document titled Assessment Template Preview indicated the Registered Nurse uses the nursing process as the framework for the management of patient (resident) care. A. Performs assess/data collection in an ongoing systematic per unit (within the unit) standards, focusing on physiological (physical, bodily), psychological (mental, emotional) and cognitive (reasoning, intellectual) status.

Based on observation, interview, and record review, the facility failed to ensure that doctor's order was verified for one out of 5 sampled residents (Resident 57), when a wound care order was written for left foot instead of the right foot (affected area). This failure had the potential to result for inaccurate care and not meeting the resident's needs. Findings: During an observation on (MONTH) 28, 2019, at 10:58 AM, Resident 57 was sitting on a chair inside his room. His right foot was observed to be swollen with bandage dressing. He stated the swelling started with a blister and was present prior to his admission in the facility. During a review of the clinical record for Resident 57, the History and Physical Exam dated (MONTH) 15, 2019, indicated [DIAGNOSES REDACTED]. A review of the doctor's order for Resident 57 dated (MONTH) 25, 2019, indicated Honey ([MEDICATION NAME] (ointment) Wound and Burn Dressing) 1 application on let foot plantar (sole) wound daily. The affected area is in the right foot. During an interview and record review with the Nurse Manager, on (MONTH) 30, 2019, at 2:35 PM, the Nurse Manager stated a wound care physician did a debridement (removal of damaged tissue from a wound) on (MONTH) 25, 2019 of the right foot, but wrote the wound care order for the left foot instead. The physician's orders [REDACTED]. A review of the Treatment Record for Resident 57 indicated that nurses signed [MEDICATION NAME] Dressing to L (left) foot plantar wound from (MONTH) 25, 2019 to (MONTH) 29, 2019. A review of the Nurses Notes dated (MONTH) 30, 2019, at 12:11 PM, indicated Resident 57 verified that the staff applied [MEDICATION NAME] on his right foot only. The facility policy and procedure titled Chart Check revised on (MONTH) (YEAR), indicated .3. Review new orders for the last 24 hours .d. Check if order(s) are in the computer correctly.

Based on observation, interview, and record review, the facility failed to follow their policy and procedure when the respiratory care assessment did not include assessment of breath sounds (airflow in the lungs) for one of five sampled residents (Resident 107). This failure had the potential to result in dyspnea (shortness of breath) and anxiety for Resident 107. Findings: A review of the clinical record for Resident 107, a document titled History and Physical (demographic information) indicated Resident 107 was admitted on (MONTH) 26, 2019, with [DIAGNOSES REDACTED]. During an observation on (MONTH) 28, 2019, at 11:30 AM, Resident 107 was observed lying in bed receiving oxygen through a nasal cannula (device that delivers oxygen through the nose). The oxygen flow meter (device that supplies continuous flow of oxygen through a tube) was set at 2 liters a minute (2LPM-unit of measurement). A review of Resident 107's care plan with the Respiratory Care Practitioner (RCP 1), initiated on (MONTH) 26, 2019, indicated Problem: Respiratory; Goal: Maintain and improve respiratory; Comments: Requiring O2 (oxygen) to maintain saturation (oxygen blood level) greater than 90 % (percent). Place on RT (respiratory treatment/therapy) and O2 protocol as ordered. Monitor for S/S (signs and symptoms) of dyspnea. Inform MD (medical doctor) for abnormal findings. During an interview with RCP 1, on (MONTH) 28, 2019, at 12:37 PM, RCP 1 stated Resident 1 is dependent on oxygen at home and the facility continued the home regime. RCP 1 further stated Resident 107 receives [MEDICATION NAME] inhalation treatments (unpressurized aerosol-hand held nebulizer) and should have a full respiratory assessment before and after each respiratory care treatment to determine the appropriateness and effectiveness of the prescribed respiratory care orders. RCP 1 stated the assessment includes but not limited to: pulse (heart rate), respiration characteristics (breathing), oxygen saturation and lung sounds. RCP 1 further stated the RCPs should notify the physician and nursing immediately of abnormal findings. During an observation with RCP 2, on (MONTH) 30, 2019, at 12:20 PM, in Resident 107's room, RCP 2 administered a [MEDICATION NAME] inhalation solution treatment. RCP 2 did not assess Resident 1's breath sounds. During an interview with RCP 2, on (MONTH) 30, 2019, at 12:39 PM, at the nurse's station, RCP 2 stated [MEDICATION NAME] inhalation treatments are indicated for residents with [MEDICAL CONDITIONS] when more than one medication is needed for the treatment of [REDACTED]. RCP 2 further stated she did not perform a complete respiratory assessment after administering the [MEDICATION NAME] treatment. RCP 2 stated Resident 107's breath sounds should have been assessed before and after a respiratory care treatment. During an interview with Respiratory Care Practitioner Supervisor (RCPS), on (MONTH) 30, 2019, at 4:10 PM, the RCPS stated RCP 2 should have assessed Resident 107's breath sound before and after the [MEDICATION NAME] inhalation treatment. A review of the facility's policy and procedure titled, Interdisciplinary Assessment and reassessment of patients (residents) revised (MONTH) (YEAR), indicated: C. Respiratory Care: Initial Assessment: . e. Patients receiving respiratory care services will be assessed to determine the appropriates and effectiveness of the prescribe respiratory care orders according to medically approved facility guidelines. 2. Reassessment: .b. The respiratory care practitioner will assess the patient's therapeutic response and continued need for all respiratory care with each procedure.

Based on interview and record review, the facility failed to ensure that the intravenous (IV-within the vein) access site was properly monitored after [MEDICAL TREATMENT] (a process of purifying the blood whose kidneys are not working normally) treatment of [REDACTED]. This failure had the potential for Resident 57 not to receive timely assessment and care for bleeding, infection, and other complications to the access site. Findings: During a review of the record for Resident 57, the History and Physical dated (MONTH) 15, 2019, indicated [DIAGNOSES REDACTED]. A review of the Acute [MEDICAL TREATMENT] Flowsheet indicated Resident 57 received an onsite [MEDICAL TREATMENT] treatment on (MONTH) 23, 2019, (MONTH) 25, 2019, and (MONTH) 28, 2019. During an interview with the Registered Nurse (RN1), on (MONTH) 29, 2019, at 4:16 PM, RN1 reviewed the clinical record and was unable to find documentation that assessment of the [MEDICAL TREATMENT] was conducted on day shift of (MONTH) 24, 2019 and (MONTH) 26, 2019. She stated they do head to toe assessment once a shift (nightshift). RN1 agreed that the [MEDICAL TREATMENT] site should be assessed for bleeding and other complications after the treatment every shift. During an interview with the Nurse Manager, on (MONTH) 30, 2019, at 8:50 AM, she stated that a focused re-assessment that may include assessment of the IV access line are only done upon change in resident's condition. The Nurse Manager stated Resident 57 was admitted due to his right foot diabetic ulcer and not because of his [MEDICAL TREATMENT]. The undated facility policy and procedure titled Care of [MEDICAL TREATMENT] Residents indicated .11. Nursing will chart post [MEDICAL TREATMENT] noting fluid output, vital signs, check fistula ([MEDICAL TREATMENT] IV access) every shift for any drainage, pain redness, swelling and resident for any fever or chills.

Based on observation, interview, and record review, the facility failed to ensure the Head to Toe Assessment (physical examination) was accurately performed and documented to include hearing loss for one of five sampled residents (Resident 107). This failure resulted in documentation that did not reflect Resident 107's current health status and had the potential to adversely affect Resident 107's psychological health and well-being. Findings: A review of the clinical record for Resident 107, a document titled History and Physical indicated Resident 107 was admitted on (MONTH) 26, 2019, with [DIAGNOSES REDACTED]. During an observation on (MONTH) 28, 2019, at 11:30 AM, Resident 107 was observed lying in bed and receiving oxygen through a nasal cannula (device that delivers oxygen through the nose). The oxygen flow meter (device that supplies continuous flow of oxygen through a tube) was set at 2 liters a minute (2LPM-unit of measurement). Resident 107 was facing the window and her back was positioned toward the door. Resident 107 did not respond to the knock at the door or to the calling of her name. During an observation on (MONTH) 28, 2019, at 1:06 PM, Resident 107 was observed lying in bed in a supine position (on the back) watching television. Resident 107 stated she was not asleep at 11:30 AM, Resident 107 stated she had recently experienced a hearing loss in the right ear. During an interview with Resident 107, on (MONTH) 28, 2019, at 1:10 PM, Resident 107 stated when she is positioned in a left lying position, It is hard to hear the staff. Resident 107 stated the phone is located on the table close to her right ear and she was embarrassed when she could not hear the dietary staff on the telephone requesting for the daily meal preference. Resident 107 stated communication preferences included: 1. Placing the phone on the left side of the bed; 2. Staff get her attention before asking questions or providing care; and 3. Staff talk to her face to face or stand on the left side of the bed when speaking to her. A review of the care plan with the Nurse Manager (NM), on (MONTH) 30, 2019, at 10:15 AM, indicated Problem: EENT (ears, eyes, nose throat)/neuro (neurology- nervous system). Goal: Maintain/improve EENT/Neuro . Comments: Risk for neurological deficit s/p (current status after procedure) ortho (orthopedic- bone structure) surgery. Plan: Assess neurological status QS (every shift) and PRN (as needed) . During a concurrent interview with the NM, the NM stated the Registered Nurse (RN) did not address Resident 107's hearing loss in the care plan that was initiated on (MONTH) 26, 2019. The NM further stated Resident 107's goals and preferences for communication should have been incorporated into the plan of care. During an interview and record review with the NM, on (MONTH) 30, 2019, at 3:58 PM, the NM stated the Head to Toe assessment dated (MONTH) 26, 2019, was incomplete due to the RN leaving the ear question blank. The NM further stated an unanswered question indicated the RN had assessed Resident 107 ears and there were no abnormalities identified. The NM stated the Admission Profile dated (MONTH) 27, 2019, under Medical History: section EENT, was left blank indicating Resident 107 did not have a problem with hearing loss. The NM stated the RN is responsible for performing an accurate assessment. She further stated Resident 107's hearing loss should have been identified and documented. A review of the facility's policy and procedure titled Documentation, Patient care revised (MONTH) (YEAR), indicated: Policy: 7. The admission assessment interventions will be completed by a Registered Nurse (RN). The nurse can skip a question or section on the assessment if they are unable to assess due to the patient's condition, but the reason must be documented .11. The RN will document a Head to Toe Assessment every shift or as defined by unit policy. A review of the facility's policy and procedure titled Interdisciplinary Assessment and Reassessment of Patients revised (MONTH) (YEAR), indicated: 4. Overview of Discipline-Specific Criteria and Procedures: Discipline: Registered Nurse. Assessment time frame: Initial assessment within 12 hours. Reassessment time frame: Minimum of daily and based on change in condition, diagnosis, treatment plan and patient response. A review of the Registered Nurse (RN) job description, undated, a document titled Assessment Template Preview indicated the Registered Nurse uses the nursing process as the framework for the management of patient (resident) care. A. Performs assess/data collection in an ongoing systematic per unit (within the unit) standards, focusing on physiological (physical, bodily), psychological (mental, emotional) and cognitive (reasoning, intellectual) status.

Based on interview and record review, the facility failed to ensure a care plan for a [MEDICAL CONDITION] medication was done for one of 10 residents (Resident 7). This failure had the potential to cause psychosocial harm that can affect a universe of 10 residents. Findings: During a closed record review of Resident 7's facesheet, it indicated Resident 7 was admitted on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. During a record review of Resident 7's physician order [REDACTED]. Sleeplessness . (MONTH) repeat x1 after 2 hours if ineffective . During a record review of Resident 7's Physician order [REDACTED]. Diagnosis: [REDACTED]. During a record review of Resident 7's MAR (Medication Administration Record), it indicated Resident 7 [MEDICATION NAME] mg on (MONTH) 10, (YEAR) [MEDICATION NAME] mg on (MONTH) 13, (YEAR). During an interview and record review with the Registered Nurse (RN 1) on (MONTH) 1, (YEAR) at 11:22 AM, RN 1 was unable to find a documentation of Resident 7's care plan for [MEDICAL CONDITION] medication. RN 1 confirmed the care plan for the [MEDICAL CONDITION] medication was missed. During a concurrent record review with the RN 1 of the Departmental Policy, titled, TCU Policy P009 Use of Psychotherapeutic Medications in TCU, dated (MONTH) (YEAR), indicated, 2.The Social Worker in collaboration with the RN will be responsible for initiating appropriate care plan goals and identifying alternate approaches that may be used in conjunction with the hypnotic. RN 1 confirmed the care plan for the [MEDICAL CONDITION] medication was missed. During a concurrent interview with RN 2, she stated she expects the nurses to do a care plan for residents who had an order for [REDACTED]. An undated policy and procedure titled, Psychotherapeutic Medications, indicated, Psychotherapeutic medications include . hypnotics . When there is a new order for a [MEDICAL CONDITION] medication . 2. Begin a Psychotherapeutic Check List . e. Care Plan .