Every finding on record at VI at Palo Alto

Based on observation, interview, and record review the facility failed to ensure Kitchen Staff F (KS F) used proper technique when testing sanitizer concentration for cleaning food contact surfaces. This failure had the potential to increase the risk of contamination and exposure to food borne illness for 37 residents in the facility.Findings: During a kitchen observation on 1/22/26, at 10:10 a.m., KS F was observed checking the sanitizer bucket used for cleaning food contact surfaces. KS F dipped the sanitizer test strip into the sanitizer solution and immediately removed the test strip. KS F did not allow the test strip to remain in the solution for the required contact time. According to the manufacturer's instructions on the Hydrion QT-40 sanitizer test strips indicated: Immerse for 10 seconds During an interview and concurrent review on 1/22/26 at 2:40 p.m., the Registered Dietitian (RD) was informed of the observation related to improper testing of the sanitizer bucket. The RD confirmed that the manufacturer's instructions on the Hydrion test strips require 10 second immersion time. The RD stated that staff should immerse the sanitizer test strip in the solution for 10 seconds and stated the facility would provide an in-service to kitchen staff.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when the shared glucometer was not sanitized and disinfected for one out of two sampled residents. This failure could result in cross-contamination and the spread of infection throughout the facility.Findings: During a medication pass observation on 1/22/26 at 11:27 a.m., Licensed Vocational Nurse (LVN) A was observed returning the glucometer to the medication cart drawer after obtaining the blood sugar reading for Resident 1 without disinfecting it. During an interview on 1/22/26 at 11:20 a.m., LVN A stated she was supposed to use the Sani-Cloth (a germicidal disinfectant) wipes to disinfect the glucometer to prevent the spread of infection between residents. LVN A stated, It's usually sanitized after every resident but I forgot. During an interview on 1/26/26 at 11:41 p.m. with the Infection Preventionist (IP), the IP stated the nurses should sanitize before and after use of the glucometer with the Sani-Cloth wipes. The IP explained the disinfection process, dwell time two minutes, the glucometer wet for two minutes. The IP stated online and in person Infection Prevention and Control in-services are conducted on a regular basis for all staff. A review of the facility's policy and procedures titled, Glucometer Quality Control Testing and Cleaning, revised October 2017 indicated, .5. The glucometer and fingerstick device is disinfected after each use using the PDI Super Sani Cloth or Sani cloth Plus or other approved cleaner noted in the manufacturer's guidelines. 5.1 Follow manufacturer's guidelines for the cleanser, which include thoroughly wetting the surface. The treated surface must remain visibly wet for a full 2 minutes and to use additional wipes as needed to assure continuous 2 minute wet contact time and let air dry.

Based on observation, interview, and record review, the facility failed to ensure comprehensive care plans were developed and revised timely for two of 12 sampled residents (Residents 30 and 7) when: 1.Resident 30's Care Plan indicated Full Code and the physician's order indicated DNR;2a.Resident 7's Care Plan indicated Full Code and the POLST indicated DNR; and2b.Resident 7's Care Plan did not indicate self-administration of medication. These failures had the potential to affect the provision of care. Findings: Review of Resident 30's Physician Order Report, dated [DATE] to [DATE], indicated Resident 30's code status was Do Not Resuscitate/Do Not Intubate (DNR, no CPR/chest compressions if the heart stops; DNI means no breathing tube or ventilator if breathing stops). Review of Resident 30's Care Plan, date [DATE], indicated the resident's code status was Full Code (all possible life-saving measures, including cardiopulmonary resuscitation (CPR) and other medical interventions, should be used in the event of a medical emergency). During a concurrent interview and record review on [DATE] at 4:00 p.m., the Director of Nursing (DON) confirmed that the care plan should have been revised to reflect the physician's order for DNR/DNI and acknowledged that the care plan was not revised. Review of facility's policy titled Care Plan Protocol revised 11/2011, indicated Revision of the plan of care as frequently as necessary to reflect the changing care needs of the patient . 2a. Review of Resident 7's Face Sheet (summary page of a patient's important information) indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including central cord syndrome (an incomplete traumatic injury to the portion of the spinal cord that runs through the bones of the neck) at C4 level of cervical spinal cord (area located in the mid-neck and critical segment for neck mobility, shoulder function and nerves that control breathing), type 2 diabetes mellitus (a condition which affects the way the body processes blood sugar) with diabetic neuropathy (nerve damage caused by long-term high blood sugar), long term use of insulin (medication used to lower blood sugar levels), chronic kidney disease (gradual loss of kidney function), hypertension (a condition in which the force of the blood in the blood vessels is too high), glaucoma (damage to the nerve in the eye cause by fluid buildup or increased pressure), rosacea (skin condition causing facial redness, visible blood vessels and bumps on face, chest, or back), and long term use of antibiotics (medications used to treat and prevent bacterial infections). Review of Resident 7's Quarterly review minimum data set (MDS - a federally mandated resident assessment tool) assessment dated [DATE], indicated a brief interview for mental status (BIMS-an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 (0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact). Review of Resident 7's Physician Order Report dated [DATE], indicated Code Status: DNR/DNI. Review of Resident 7's POLST (Physician Orders for Life-Sustaining Treatment- a written medical order that assists people in making decisions about medical treatment and life saving measures during end-of-life care or a medical crisis) dated and signed by Resident 7 on [DATE] indicated, Do Not Attempt Resuscitation/DNR (Allow Natural Death). Review of Resident's 7's Care Plan dated [DATE] indicated Advance Directives (a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions): Resident's code status is: Full Code. During an interview on [DATE] at 3:32 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, A resident's care plan should be updated whenever there is a change. During an interview on [DATE] at 3:00 p.m., with the DON, the DON stated the POLST, Advanced Directives and care plan should match. Review of the facility's policy and procedure titled, Advanced Directives Protocol, revised [DATE], indicated, Determination of Advance Directives Upon Admission- Upon admission, the resident and/or responsible agent and/or Durable Power of Attorney for Healthcare (DPAH) are asked if the resident has executed an advance directive (AD). 1. If the resident has executed an AD, a copy of the document is requested. 6.1. Document the status of the advance directive in the care plan or service plan. 2b. During a concurrent observation and interview on [DATE], at 11:27 a.m., with Resident 7, one opened container and one unopened container of anti-fungal powder was observed on the over bed table in Resident 7's room. Resident 7 stated she used the anti-fungal powder on the irritated area on her abdomen during her stay in the facility. During an interview on 1/21/ 26 at 12:04 p.m. with LVN B, LVN B confirmed the two containers of anti-fungal powder were on the over bed table in Resident 7's room. LVN B stated not knowing the anti-fungal powder containers were at the resident's bedside and didn't know if the containers should be in the resident's room. During an interview and concurrent review of Resident 7's Physician Orders and Care Plan on [DATE] at 3:00 p.m., the DON stated Resident 7 had not been assessed for self-administration of medication and did not have an order or a care plan for self-administration of any medication. During a review of the facility's policy and procedure title, Medications-Bedside Storage and Self-Administration, revised [DATE], indicated Prescription and nonprescription over the counter (OTC) medications, except narcotic analgesics and other Class II drugs, may be stored at the bedside in a secure, locked drawer when ordered by a healthcare provider with prescriptive authority, and after the assessment and approval by the interdisciplinary team of the resident's ability to self-administer medication. 1. The order received for the medication to be used/stored at the bedside includes directions for use and specifies that the medication is to be stored at the bedside. All bedside medications are labeled as such and stored securely under lock and key. 3. Any resident who has bedside medications is instructed on the proper use and storage of the medication. 4. Items documented in the resident's plan of care include but are not limited to the following: Assessment confirmation of ability to self-administer; Authorization from the healthcare provider with prescriptive authority; and Relevant safety issues.

Based on interview and record review, the facility failed to act upon the pharmacy consultant's medication regimen review recommendation for one of 12 sampled residents (Resident 1). This failure had the potential to affect the safety and management of the resident's medication regimen. Findings: Review of Resident 1's clinical record indicated diagnoses including benign prostatic hyperplasia (BPH, enlargement of the prostate gland). Review of Resident 1's Physician Orders, dated 12/23/25 through 1/23/26, indicated an order for Tamsulosin (medication that helps relax prostate and bladder) 0.4 milligrams (mg, unit of weight) one capsule by mouth twice a day for BPH. Review of Resident 1's admission Medication Regimen Review, dated 12/26/25, indicated the consultant pharmacist recommended updating the instructions to Tamsulosin 0.4 mg, take two capsules (0.8 mg) by mouth once daily, to be administered 30 minutes after the evening meal, and that the capsules should not be crushed, chewed, or opened. During a concurrent interview and record review on 1/23/26 at 3:30 p.m., the Director of Nursing (DON) stated the physician had been notified. Further review, of Resident 1's medical record did not show documentation of physician notification or documentation of physician's response to the pharmacist's recommendation. The DON acknowledged that documentation of physician's response to pharmacist recommendations and rationale if the physician agreed or disagreed, should be documented in the medical record. During a phone interview on 1/26/26 at 10:40 a.m., the Consultant Pharmacist (CP) stated she completes monthly drug regimen reviews. The CP further stated that she reviewed Resident 1's physician orders and confirmed that the Tamsulosin recommendation was not carried out. Review of facility's policy titled Drug Regimen Review, revised 10/2023, indicated, .The Pharmacist will make a written report of any irregularities to the resident's attending physician, the Community's Medical Director, and the Director of Nursing on the Drug Regimen Review Irregularity Report or comparable pharmacy Drug Regimen Review Report .The resident's attending physician will document in the clinical record that the Drug Regimen Review Irregularity Report was reviewed. The physician will also document any action that must be taken to address the irregularity. If no change to the resident's medication is made, the physician will document his or her rationale in the clinical record. Should any potential or actual clinically significant medication issues be identified, throughout the resident's stay, the clinician will contact the physician and complete the prescribed/recommended actions by midnight of the next calendar day. This will be documented in the electronic health record in a Drug Regimen Review progress note or in an Event report if related to a medication error .

Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when inspection of two of three medication carts identified an insulin pen without a visible resident's name on it. This failure had the potential for the unlabeled insulin to be administered to the wrong resident. Findings:Findings: During an inspection of Medication Cart #3 on 1/26/26 at 10:59 a.m. with Registered Nurse (RN) C, an insulin pen (a pre-filled pen containing insulin to lower blood sugar) was identified opened and did not have resident specific labeling on it. RN C verified this finding and acknowledged it should have a label to indicate the name of the resident. During an interview on 1/26/26 at 3:26 p.m. with the Director of Nursing (DON), the DON confirmed the insulin pen did not have a resident specific label. The DON stated the resident specific label is only placed on the box of insulin pens when delivered from the pharmacy and stored in the refrigerator in the Medication Room. The DON confirmed one pen would be removed from the refrigerator, placed in a cellophane bag labeled with the resident's name and left in the medication cart for multiple administrations for the resident. A review of the 2017 Institute for Safe Medication Practices (ISMP, a nonprofit patient safety organization with recognized national expertise in medication error prevention) Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults, indicated, If an institution chooses to use insulin pen devices, each should contain a patient-specific label and be stored in a patient-specific bin/drawer . to prevent contamination from inadvertent misuse on another patient. A review of the facility's Policy and Procedure titled Medication Management Protocol, revised June 2011 indicated: Storage of Medications 1. Resident medications are packaged by a pharmacy and labeled accordingly with the: Name of the prescribing healthcare provider; Resident's name; Date dispensed; Name and strength of medication; Directions for usage; Time to be taken; and Other directions and restrictions (e.g., with food, 1 hour after eating). The prescription number, name and address of the issuing pharmacy. 1.1. Medications packages having soiled, damaged, incomplete, illegible or makeshift labels are returned to the issuing pharmacy for disposal or re-labeling.

Based on observation, interview, and record review, the facility failed to follow their restraint protocol and ensure the proper use of side rails or bed canes (adjustable rigid bars attached to the side of a bed) for nine (Residents 1, 12, 22, 26, 32, 33, 191, 243, and 246) of 24 residents (residents who used side rails or bed canes) when: 1. Resident 1 there was no physician order, side rail assessment, consent, or care plan for the use of side rails; 2. For Resident 243 there was no physician order or care plan for the use of bed canes; 3. For Resident 246 there was no physician order for the use of bed canes; 4. For Resident 191 there was no physician order or care plan for the use of bed canes; 5. For Resident 12 there was no physician order or consent for the use of bed canes; 6. For Resident 22 there was no consent for the use of bed canes; 7. For Resident 33 there was no consent for the use of bed canes; 8. For Resident 32 there was no consent for the use of bed canes; and 9. For Resident 26 there was no physician order for the use of bed canes. These failures had the potential to compromise the residents' rights to be fully informed, and make decisions regarding their care and treatment, and result in the residents not receiving the care and services necessary to maintain their health, safety, and well-being. Findings: 1. During an observation on 8/19/24, at 11:25 a.m., Resident 1 was lying in her bed and had upper half-length side rails (cover a portion of the bed, typically half the length). The side rails were in the upright position bilaterally (on both sides). Review of Resident 1's clinical record indicated there was no physician order for Resident 1's use of the side rails. Further review of Resident 1's clinical record indicated there was no consent, no side rail assessment, or no care plan documented for Resident 1's use of side rails. During a concurrent interview and record review with the DON on 8/20/24, at 3:35 p.m., the DON reviewed Resident 1's clinical record and confirmed there was no physician order, no consent, no side rail assessment, or no care plan in place for Resident 1's use of the half- length side rails. The DON stated there should have a physician order, a signed consent, and a side rail assessment prior to the installation of the side rails. The DON further stated a care plan should have been developed and implemented for Resident 1's use of side rails. 2. During an observation on 8/19/24, at 12:05 p.m., Resident 243 was lying in her bed and had bed canes in the upright position bilaterally, attached at the head position of her bed frame. During a concurrent interview and record review with the DON on 8/20/24, at 3:35 p.m., the DON reviewed Resident 243's clinical record and confirmed there was no physician order or care plan in place for Resident 243's use of the bed canes. The DON stated there should have been a physician order prior to the installation of the bed canes. The DON stated residents who had bed canes in used should have a care plan in placed. The DON further stated care plans were important for nurses to know the proper implementation and interventions related to bed cane use. 3. During an observation on 8/19/24, at 1:05 p.m., Resident 246 was lying in her bed and had bed canes in the upright position bilaterally, attached at the head position of her bed frame. During a concurrent interview and record review with the DON on 8/20/24, at 3:35 p.m., the DON reviewed Resident 246's clinical record and confirmed there was no physician order in place for Resident 246's use of the bed canes. The DON stated there should have been a physician order prior to the installation of the bed canes. 42819 4. During an observation of Resident 191's room on 8/19/24 at 2:09 p.m., Resident 191's bed had bilateral partial bed canes up. Review of Resident 191's face sheet (summary page of patients' important information), indicated that resident was admitted to the facility on [DATE]. Review of Resident 191's active physician orders and care plans indicated that there was no order or care plan for the use of bed canes. During an interview with the DON on 8/21/24, at 2:10 p.m., the DON stated that there should have been a physician order and care plan for the use of bed canes. During a concurrent interview and record review on 8/23/24, at 1:30 p.m. with the DON. The DON reviewed Resident 191's restraint/adaptive equipment use assessment, physician orders, and care plans, and confirmed that there was no physician order or care plan in place for the bed canes. 48935 5. Review of Resident 12's facesheet indicated she was admitted to the facility on [DATE] with a diagnosis of aftercare following joint replacement surgery, placement of left artificial knee joint and urinary tract infection. Review of Resident 12's minimum data set (MDS, a resident clinical and functional assessment tool) assessment, dated 8/2/24, indicated Resident 12 had a brief interview for mental status (BIMS, an assessment used in nursing homes to monitor cognition) score of 13 (a score of 13-15 indicates minimal cognitive impairment). Review of Resident 12's record indicated there was no physician order for the use of bed canes or an informed consent for the use of bed canes signed by either the Resident or Responsible Party. Review of Resident 12's record indicated a care plan was in place for the use of bed canes, to enable with transfers. During an observation on 8/19/24 at 9:28 a.m., Resident 12 was observed in bed, with two bed canes in a fixed position. 6. Review of Resident 22's facesheet indicated he was admitted to the facility on [DATE] with a diagnosis of atrial flutter (an irregular heart rhythm), vascular parkinsonism (a disease of the brain and motor function), and insomnia. Review of Resident 22's MDS, dated [DATE], indicated Resident 22 had a BIMS score of 7 (a score of 0-7 indicates severe cognitive impairment). Review of Resident 22's record indicated a physician order May use bilateral bed canes as enabler for assistance with transfers, bed mobility and aid in positioning while at SNF, dated 2/24/21. Review of Resident 22's record indicated there was no informed consent on file for the use of bed canes signed by either the Resident or Responsible Party. Review of Resident 22's record indicated a care plan was in place for the use of bed canes, to enable with transfers. During an observation on 8/19/24 at 11:45 AM, Resident 22 was observed in bed, with two bed canes in a fixed position. 7. Review of Resident 33's facesheet indicated she was admitted to the facility on [DATE] with a diagnosis of atrial fibrillation (an irregular heart rhythm), previous stroke (a brain attack), and type 2 diabetes mellitus (a disorder that affects insulin and blood sugar levels). Review of Resident 33's MDS , dated 8/9/24, indicated Resident 33 had a BIMS score of 14. Review of Resident 33's record indicated a physician order May use bilateral bed canes as enabler for assistance with transfers, bed mobility and aid in positioning while at SNF, dated 5/26/24. Review of Resident 33's record indicated there was no informed consent on file for the use of bed canes signed by either the Resident or Responsible Party. Review of Resident 33's record indicated a care plan was in place for the use of bed canes, to enable with transfers. During an observation on 8/19/24 at 11:17 AM, Resident 33 was observed in bed, with two bed canes in a fixed position. 8. Review of Resident 32's facesheet indicated he was admitted to the facility on [DATE] with a diagnosis of paroxysmal atrial fibrillation (an irregular heart rhythm), type 2 diabetes mellitus and unsteadiness on feet. Review of Resident 32's MDS, dated [DATE], indicated Resident 32 had a BIMS score of 15. Review of Resident 32's record indicated a physician order May use bilateral bed canes as enabler for assistance with transfers, bed mobility and aid in positioning while at SNF, dated 4/4/24. Review of Resident 32's record indicated there was no informed consent on file for the use of bed canes signed by either the Resident or Responsible Party. Review of Resident 32's record indicated a care plan was in place for the use of bed canes, to enable with transfers. During an observation on 8/19/24 at 11:17 AM, Resident 32 was observed in bed, with two bed canes in a fixed position. 9. Review of Resident 26's facesheet indicated she was admitted to the facility on [DATE] with a diagnosis of fracture of lower end of right femur (right thigh bone), status post ORIF (open reduction internal fixation, a surgery to repair the bone) right femur, and hypertension (high blood pressure). Review of Resident 26's MDS, dated [DATE], indicated Resident 26 had a BIMS score of 15. Review of Resident 26's record indicated there was no physician order for the use of bed canes. Review of Resident 26's record indicated there was a signed informed consent on file for the use of bed canes, dated 7/31/24 Review of Resident 26's record indicated a care plan was in place for the use of bed canes, to enable with transfers. During an observation on 8/19/24 at 10:01 a.m., Resident 26 was observed in bed, with two bed canes in a fixed position. During an interview with the director of nursing (DON) on 8/21/24 at 1:57 p.m., the DON stated there should have a physician order for Resident 12 and 26. DON also stated there should have informed consent for Resident 12, 22, 33, and 32. A review of the facility's policy titled Restraint Protocol, revised October 2023, indicated . 3. If side rails are used as enablers, the Side Rail(s) Use Assessment in Matrix is completed. 4. The following items are also documented if side rails as enablers are going to be used: .Resident/responsible agent signed the Physical Restraint/Adaptive Equipment consent permitting the use of side rails as enabler; and Receipt of order authorizing the use of side rails. 5. Residents are assessed at least quarterly for continued need of side rails as enablers.

Based on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: 1. There was an opened undated food item in the pantry freezer; 2. There were open and undated food items, and unopened food items with no expiration dates in the dry storage area of the main kitchen. These failures had the potential to cause food contamination and food-borne illness to 37 of 37 residents who received their food from the kitchen. 1. During an initial kitchen tour on 8/19/24 at 9:20 a.m., accompanied by the Executive Chef (EC), inside the reach-in freezer there was an opened, undated container of mango sorbet. The EC confirmed the sorbet was opened and not dated and he stated all items should have been dated when opened. The EC stated the mango sorbet must be discarded. 2. During a continuation of the initial kitchen tour on 8/19/24 at 9:45 a.m., accompanied by the EC, an inspection of the main kitchen dry storage area was conducted. There was a box labeled [NAME] French Lentils which contained an opened bag of lentils. The open bag was undated. The EC stated the bag should have been dated when opened and he stated the lentils must be discarded. In addition, the dry storage area contained four 2- pound bags of chopped peanuts. The four bags were unopened but did not have an expiration date on the bags. The EC stated the bags had been removed from their original box for storage on the shelves and the expiration date would have been on the original box. The EC stated the four bags of peanuts must be discarded since their expiration date was unknown. Review of the facility's policy titled Sanitation and Safety, revised June 2011, indicated . 5. Labeling and dating food; Prepared and packaged food will be labeled and rotated to decrease the risk for food-borne illnesses, provide the highest quality product for the residents and minimize waste.

Based on observation, interview, and policy review, the facility failed to protect the rights of residents to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service) when staff members left the computer screen open and unattended in the hallways of resident care areas. This deficient practice had the potential to compromise the rights of the residents to privacy and confidentiality. Findings: During an observation on 8/19/24 at 1:00 p.m., a rolling cart containing an open laptop computer was left unattended in the hallway outside of a resident's room. The laptop computer was on and the screen displayed information about multiple residents. On 8/19/24 at 1:08 p.m., certified nursing assistant A (CNA A) returned to the computer. When CNA A was asked about the resident information visible on the screen, CNA A stated she was working on that computer then left to answer a call light and did not close the laptop. CNA A stated she should have not leave the computer screen open and visible to visitors and residents. During an observation on 8/22/24 at 8:25 a.m., a rolling cart containing an open laptop computer was left unattended in the hallway outside of a resident's room. The laptop computer was on and the screen displayed multiple resident's pictures and information about multiple residents. On 8/22/24 at 8:35 a.m., CNA B returned to the computer. When asked about the laptop being open and the resident information visible to the public, CNA B stated he should have closed the laptop when he leaves the area. CNA B stated he had stepped away from his working on the laptop to answer a resident's call light. CNA B stated I should not leave the computer open with the resident information on the screen. Anyone passing by can see it During an interview with the director of nursing (DON) on 8/22/24 at 8:45 a.m., DON was asked what was the process for protecting resident's personal information when laptops are used in the resident care areas. The DON stated the laptop computers should have be put on a locked screen when staff need to step away from the computer. The DON further stated the patient information should have not visible to the public and left the computer unattended. A review of the facility's policy titled HIPPA Security, revised June 2011, indicated Electronic Protected Health Information (ePHI) is any and all information about an individual's health care plan(s) that is stored or transmitted electronically. The Health Insurance Portability and Accountability Act (HIPPA) mandates that ePHI be safeguarded and protected and that employees comply with the act. The policy further indicated 1. Employees who, in the normal course of their job responsibilities, come in contact with ePHI are obligated to safeguard and keep such information secure . 2. Systems containing ePHI are kept secure by various means including .Logging off immediately when leaving a workstation.

Based on observation, interview and record review, the facility had a facility medication error rate of 7.59% when two medication errors occurred out of 26 opportunities during medication administration for two out of 5 residents (Resident 21 and Resident 32). This failure resulted in medication not given in accordance with the prescriber's orders which resulted in residents not receiving the full therapeutic effects of the medications. Findings: 1. During a concurrent medication pass observation and interview on 8/19/24 at 11:00 AM with registered nurse (RN) C , RN C administered Timolol (an eye drop medication) to Resident 21, one eye drop in each eye. RN C then administered Simbrinza (another eye drop medication) one eye drop in Resident 21's left eye without waiting 5 minutes after giving the Timolol. RN C stated I should have wait 5 minutes before giving the other eye drop. During an interview with the director of nursing (DON) on 8/22/24 at 11:45 a.m., the DON stated she expects staff to wait 5 minutes between eye drops if residents get more than one eye drop. A review of Resident 21's physician order, dated 12/17/2022 indicated Resident 21 was to receive Timolol , one eye drop in both eyes, once a day at 9:00 a.m. for indication of glaucoma (a disorder of the eyes caused by high eye pressure). Special instructions indicated Wait at least 5 minutes before any other eye drops. A review of Resident 21's physician order, dated 12/17/2022 indicated Resident 21 was to receive Simbrinza one eye drop in the left eye, three times a day at 9:00 a.m., 5:00 p.m., and 9:00 p.m., for indication of glaucoma. Special instructions indicated Wait at least 5 minutes before any other eye drops. Review of facility policy titled Specific Medication Administration Procedures-IIB5: Eye Drop Administration, last revised 5/16/2018, indicated .If another drop of the same or different medication is prescribed for administration in the same eye at the same time, wait 10 minutes, (or the amount of time specified by the manufacturer) then repeat procedure above. 2. During a concurrent medication pass observation and interview on 8/20/24 at 4:29 PM with LVN E, LVN E administered 3 units of novolog (a type of insulin injection) to Resident 32 with a pen injector (an injector that uses a dial to administer the correct medication dosage). Prior to administering the 3 units, LVN E did not prime the pen injector needle with 2 units of novolog. LVN E stated I did not know about it when asked about priming a pen injector needle prior to giving a dosage of novolog. A review of Resident 32's physician order, dated 8/10/24 indicated Resident 32 was to receive insulin aspart U-100 (novolog, medication for blood sugar) per sliding scale, before meals at 6:30 a.m., 11:30 a.m., and 4:30 p.m. The order also indicated If blood sugar was between 201-250, give 3 units. Review of Lexidrug UpToDate indicated for insulin aspart administration .For prefilled pen injectors, prime the needle before each injection with 2 units .

Based on observation, interview, and record review, the facility failed to implement infection prevention and control practices for two out of two sampled residents when: 1) A Licensed Vocational Nurse E (LVN E) did not disinfect a glucometer after using it to test a resident's blood sugar (Resident 32). 2) A Registered Nurse C (RN C) did not scrub the hub (an endcap) at the end of a peripherally-inserted central catheter (PICC, a type of tube that goes directly to the heart) line for 15 seconds before flushing the PICC line with normal saline solution and before connecting the intravenous (IV) drug tubing to the PICC line (Resident 191). 3) RN D did not wear gloves when removing a medicated patch from a resident's chest, then did not wear gloves or perform hand hygiene when applying a new medicated patch to the resident's chest (Resident 15). These deficient practices had the potential to result in transmission of infection causing agents to the residents in the facility. Findings: 1. During a concurrent observation and interview with LVN E on 8/20/24 at 4:29 PM, LVN E used a glucometer (a device that checks blood sugar levels) but did not disinfect the glucometer after usage. LVN E stated I will do it . During an interview with the director of nursing (DON) on 8/22/24 at 11:45 AM, the DON stated I expect the staff to wipe the glucometer after using it. Review of facility policy titled Glucometer Quality Control Testing and Cleaning, last revised October 2017, indicated .The glucometer and fingerstick device was disinfected after each use using the PDI Super Sani Cloth or Sani Cloth Plus or other approved cleaner noted in the manufacturer's guidelines. 2. During a concurrent observation and interview with RN C on 8/20/24 at 10:50 AM, RN C scrubbed the end cap with a rubbing alcohol swab at the end of Resident 191's PICC line for less than 10 seconds, before connecting a syringe pre-filled with normal saline solution (a solution used to ensure the PICC line is unblocked from debris build up), and then between flushing the PICC line and between connecting the IV drug tubing to the PICC line. RN C stated I am supposed to scrub for 60 seconds, when asked how long the end cap must be wiped for. Review of literature pertaining to the care of central venous catheters and PICC lines titled CLABSI Toolkit-Scrub the Hub! indicated .Use a scrubbing device with an alcohol product such as chlorhexidine with alcohol or 70% alcohol to disinfect catheter hub and stopcocks[ .]Rub for 10 to 15 seconds (unless directed otherwise by the manufacturer's instructions), generating friction by scrubbing in a twisting motion as if you were juicing an orange (The Joint Commission. Preventing Central Line-Associated Bloodstream Infections: Useful Tools, An International Perspective. [DATE]. Accessed August 23rd, 2024) 3. During a concurrent observation and interview with RN D on 8/19/24 at 11:15 AM, RN D removed a medicated patch without performing hand hygiene or putting on gloves from Resident 15's upper chest. RN D also did not perform hand hygiene or put on gloves before applying a new medication patch to Resident 15's upper chest. RN D stated I don't use gloves because the patch gets stuck on my gloves, when asked about removing and applying the medicated patch without wearing gloves. During an interview with the DON on 8/22/24 at 11:45 am, the DON stated I expect staff to wear gloves when removing an old patch and putting on a new patch, and performing hand hygiene before donning gloves. Review of facility policy titled Specific Medication Administration Procedures-IIB13: Transdermal Drug Deliver System (Patch) Application, last revised 5/16/18, indicated before administration to .Wash hands or use facility-approved sanitizer . Put on examination gloves . Remove old patch from body by using gloved hands to peel off slowly .Using gloves unwrap the new patch .Apply new patch firmly against the skin .Wash hands thoroughly with antimicrobial soap and water or facility-approved hand sanitizer.

Based on observation, interview and record review, the facility failed to provide appropriate pharmaceutical services when there were discrepancies between the controlled drug (those with high potential for abuse and addiction) record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for two out of two residents (Residents 140 and 26). This failure resulted in the facility not having accountability of controlled medications, which had the potential for misuse or diversion. Findings: During the survey, two random CDRs for two residents (Residents 140 and 26) were requested for review. On 8/22/24 at 11:00 AM, a review of the residents' physician orders, the CDRs and MARs indicated the following: 1. Resident 140 had a physician order, dated 8/5/24 for oxycodone (pain medication) 5 milligrams one tablet ever 4 hours PRN (as needed) for mild to moderate pain. Resident 140 had two instances initially noted to be in the CDR but not documented as given in the MAR: On 8/19/24 at 12:40 a.m., 8/19/24 at 8:40 a.m. and 8/20/24 at 8:40 p.m. 2. Resident 26 had a physician order, dated 7/31/24 for oxycodone 5 milligrams 1-2 tablet every 4 hours PRN for mild to moderate pain. Resident 26 had one instance which was recorded in the CDR but not in the MAR dated on 8/17/24 at 11:12 a.m. During a concurrent record review and interview with the director of nursing (DON), another instance was noted to be in the CDR for Resident 140 but not in the MAR dated on 8/19/24 at 8:40 PM. The DON confirmed the missing documentation for Resident 140, and Resident 26 on the MAR. The DON stated administration of controlled substances must be recorded in the controlled drug record and the MAR. The DON also stated We would have to provide education to the staff about documenting in both the MAR and CDR. Review of facility policy titled Medication/Treatment Management Protocol, last revised October 2023, indicated .Controlled substances are signed-off on the medication/treatment record in EMAR as well as on the Controlled Substance Record/signature page, if not automated .

Based on interview and record review, the facility failed to provide adequate assessment and supervision to prevent an accident for one of three residents (Resident 1) when physical therapy (PT, a healthcare profession that helps you move better or strengthen weakened muscles) did not follow physician's orders to assess Resident 1's functional ability level upon admission and develop a resident-centered plan of care. This resulted in Resident 1's fall, head injuries, multiple fractures, and subsequent death. Findings: Review of Resident 1's face sheet (a document that gives a resident's information at a quick glance) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), congestive heart failure (heart muscle does not pump blood as well as it should), atrial fibrillation (irregular heartbeat), osteoporosis (condition that causes the bones to become brittle and fragile), long term use of anticoagulant (blood thinner), urinary incontinence (the loss of bladder control), chronic kidney disease (loss of kidney function), and a history of falling. Review of Resident 1's Progress Notes (PN) dated 8/2/23 4:25 p.m., indicated admitted a XXX y.o. (year old) female from IL (Independent Living), via w/c (wheelchair) at 11:30 AM, accompanied by the [family member], . and the Director of IL. With the dx (diagnoses) of Chronic Heart Dis (Chronic Heart Disease, type of heart disease that affects your heart function repeatedly and over time), Chronic kidney disease, stage 4 (severe loss of kidney function), CHF (Congestive Heart Failure, heart does not pump blood as well as it should) Alert/oriented with forgetfulness, reality orientation as needed Handle gently suring (typo during) ADL'S and transfer Extensive assist with ADL's & transfer. Review of Resident 1's Observation Detail List Report with Observation Date: 8/2/23 4:34 p.m., indicated Admission Observation, OBSERVATION DETAILS, General Admission Information, . Mode of Transfer: Wheelchair . Resident Arrived With: Wheelchair Level of Consciousness: Alert . NERVOUS SYSTEM: Cognition: Attention: Attentive, Orientation: Disoriented (i.e. time, place, situation), Memory: Impaired, Thinking: Disorganized (rambling, incoherent,, impaired judgment), .GASTROINTESTINAL SYSTEM: Gastrointestinal History: Date of Last BM (bowel movement): 08/02/2023, . Resident's Current Bowel Continence Level: Occasionally incontinent, . GENITOURINARY: Genitourinary History: Current Urinary Continence Level: Occasionally incontinent, Incontinence Pattern: Unable to get to toilet in time due to urgency, .Management of Bladder incontinence: Adult briefs/Depends (underwear), . MUSCULOSKELETAL SYSTEM: Musculoskeletal History and Physical Observation: Does the resident present with any of the following (checked): Extremity weakness, History of Joint Replacement, Requires Assistive Devices, . Assistive Devices: Walker, Wheelchair, .Observe extremities for any pain, swelling, weakness, stiffness, warmth, tenderness, loss of sensation, change in color, or impaired function indicate location(s) (checked): Right Lower Extremity - Gen (generalized) weakness, Left Lower Extremity - Gen weakness Review of Resident 1's Physician's Progress Notes with Encounter Date 8/2/23 written by Physician (PHYS), indicated .Pls. see EPIC (a medical record system) reports for evaluations from [name of 3 Physicians] and fell ow at [name of clinic] colleagues for care and goals of care discussions leading to current placement in long term care Functionally now at 1-2 person assist with transfer, ADL's Durable medical equipment: 4WWalker (4-wheel walker), Electric Scooter, Walk in tub, Grab bars, adjustable bed with transfer handles, Emergency call devices Review of Resident 1's PN: PN dated 8/6/23 indicated Resident 1 had an unwitnessed fall with subsequent pain on 8/6/23 and was transferred to the hospital that day; PN dated 8/8/23 indicated Resident 1 returned to the facility on hospice (focuses on a person's quality of life as they near the end of life) care on 8/8/23, with diagnosis of subarachnoid bleed (bleeding in the space between the brain and the surrounding membrane); PN dated 8/20/23 indicated Resident 1 passed away in the facility on 8/20/23. Review of Resident 1's acute hospital CT scan (computerized tomography scan, procedure used to view internal components of the body) to head, cervical (neck) and spine dated 8/6/23, indicated Resident 1 had Multicompartment intracranial hemorrhage [bleeding in multiple parts of the head] including a moderately sized intraparenchymal hematoma [a pool of blood in the tissue of the brain] in the right frontal operculum [part of the brain], with associated subarachnoid hemorrhage in the left collateral sulcus [a part of the brain] of the temporal lobe. Findings are most compatible with traumatic subarachnoid hemorrhage. Review of Resident 1's acute hospital X-ray (images of internal tissues, bones, and organs on film or digital media) to shoulders dated 8/6/23, indicated Resident 1 had an Acute [sudden onset] mildly displaced fracture [partial or complete break in the bone] at the surgical neck of the humerus [upper arm bone]. Review of Resident 1 's acute hospital CT scan to chest dated 8/6/23, indicated Resident 1 had Few lateral nondisplaced [aligned] right rib fractures. Review of Resident 1's Minimum Data Set (MDS, a clinical assessment tool), dated 8/14/23, indicated Resident 1 had a brief interview for mental status [BIMS, a tool used to assess cognition (knowing, learning, and understanding things)] score of 6 [a score of 0 to 7 indicates severe cognitive impairment, 8-12 moderate impairment, 13-15 patient is cognitively intact]. Review of Resident 1's fall care plan dated 8/3/23, indicated following interventions to prevent falls: - Provide resident an environment free of clutter and floor free of glare, liquids and/or foreign objects. - Keep call light and personal and frequently used items within reach. - Keep bed in lowest position with brakes locked. - Encourage resident to use environmental devices such as hand grips, handrails, etc. - Educate and remind resident to ask for assistance with transfers and ambulation. Review of Resident 1's Physician's orders dated 8/2/23, indicated Occupational therapy (health care profession that help improve the ability to perform activities of daily living) evaluation and treatment (see OT POC [plan of care] for treatment modalities, frequency, and duration). Physical therapy evaluation and treatment (see PT POC for treatment modalities, frequency, and duration). Rehab potential: Fair). During an interview on 1/3/24 at 10:50 a.m. with Certified Nursing Assistant (CNA) A, CNA A stated depending on the resident's condition, PT should have assessed resident's functional level upon admission, and then therapy department would update nursing. She further stated staff would check on residents frequently and place confused residents close to staff who can keep an eye on them to prevent falls. During a concurrent interview and record review on 1/3/24, at 11:08 a.m., with Registered Nurse (RN) B, review of Resident 1's Fall Risk assessment dated [DATE], indicated a score of 17 (0-5 Low Fall Risk, 6-13 Moderate Fall Risk, >13 High Fall Risk), which indicated Resident 1 was high fall risk. RN B stated therapy should have assessed the Resident 1's transfer status (how a person can move from one position to another, example from bed to chair) to determine what level of assistance was required. During an interview on 1/3/24 at 11:43 a.m. with the Director of Rehabilitation Services (DOR), the DOR stated therapy was to assess a resident's functional level if there was a physician order, but it also depended on the resident's payer source, it had to be verified before any treatment. Since walking was not one of Resident 1's goals, PT did not evaluate her. During an interview on 2/7/24, at 2:36 p.m., with the Director of Nursing (DON), the DON stated on the day of the fall, the assigned CNA for Resident 1 changed the resident and got her ready in the morning, helped her to get out of the bed, sat the resident in the wheelchair next to the bed, placed the over bed table in front of the resident, then left the room. When the CNA came back to the room, she found that Resident 1 had fallen in the bathroom with her walker by her side. She further stated Resident 1 possibly stood up on her own, walked to the walker across the room, went to the bathroom then fell in there and hit her head. The resident required extensive assist (individual would not be able to perform or complete the activity of daily living without another person to aid in performing the complete task, by providing weight-bearing assistance) for transfer and no staff was aware that the resident was able to stand up and walk prior to the fall. During an interview on 3/6/24, at 1:20 p.m., with the DON, she stated therapy was verifying Resident 1's payer source, which usually takes several days. However, Resident 1 fell and went to the hospital before the payor source was verified. Resident 1 was then admitted to hospice upon return, so therapy did not pursue to assess her. Review of Resident 1's Certificate of Death dated 8/24/23, indicated Resident 1 passed away in the facility on 8/20/24, the immediate cause of death was A. Multiple blunt force injuries to include multicompartmental intracranial hemorrhage. B. Fall. A review of the facility's policy and procedure (P&P) titled Medicare / Managed Care Admission Protocol revised October 2017, the P&P indicated, Supportive Data: It is important to consider Medicare qualifications before the resident is admitted . During the inquiry and admission process, many activities take place simultaneously Physician orders: 2. Upon admission, physician orders for a Medicare A/Managed Care stay include, but are not limited to: An order for Evaluate and Treat for therapy services which proceeds evaluation; . A review of the facility's policy and procedure titled Fall Prevention Protocol revised October 2017, indicated, Purpose: This protocol describes mechanisms for assessing residents at risk for falls and providing interventions to reduce the likelihood of falls Assessment: 1. The John Hopkins Fall Risk Assessment is completed in the electronic medical record within 24 hours of admission for all SN (Skilled Nursing) residents Interventions: The following interventions are considered for residents who are at risk for falls: 1. Resident and/or family/responsible agent are instructed on physical activity strengths and limitations 7. The resident environment is routinely assessed for safety 8. Assistive devices used by the resident are placed within the resident's reach and are in good working order 10. Frequent rounds are made to check the resident 12. Where appropriate, a referral to rehabilitative therapy services is made to obtain interventions or recommendations to reduce fall occurrences. 12.1 If a resident is not a candidate for formal rehabilitative therapy services, consider including in the Restorative Nursing Program, as appropriate 13.1 The resident is also assessed for the appropriateness of the use of bed/chair alarm, personal alarm, and motion sensor systems 15. The resident is placed in a room close to the nursing station, if possible 17. Address any sensory deficits, especially hearing and vision, to minimize the effects of these deficits as much as possible. 18. Instruct resident to rise slowly from a standing or sitting position and to remain in a standing position until they feel balanced enough to begin walking.

Based on interview and record review, the facility failed to ensure an environment free of accidents when one of three sampled residents (Resident 1) fell during mechanical lift transfer. This failure resulted in Resident 1 sustaining lots of bruises to the body and had been feeling fearful during transfers. Findings: During a review of Resident 1 ' s activity of daily living (ADL) care plan (CP) dated 1/31/20, the CP indicated Resident 1 had self-care deficit and decreased physical mobility due to generalized weakness, may use Hoyer lift (a mechanical lift with a sling) for transfer with two people assist. During a review of Resident 1 ' s minimum data set (MDS, a clinical assessment) dated 10/28/23, the MDS indicated Resident 1 ' s brief interview of mental status (BIMS, a brief cognitive screening measure that focuses on orientation and short-term word recall) score 12, which indicated Resident 1 was cognitively intact. During an interview on 2/7/24 at 1:15 p.m. with Resident 1, the resident stated the CNA [certified nursing assistant] was trying to transfer her from the chair to bed, then the strap of the Hoyer pad snapped, and she fell . She was not sure where she had landed, but she was having pain after the fall and got a huge bruise to the left side of her body. She further stated she still didn ' t feel safe and felt apprehensive every time during transfer. During an interview on 2/7/24 at 1:38 p.m. with CNA A, CNA A stated she was going to give Resident 1 a shower the day after the incident, then she found a lot of bruises on the resident ' s body. The resident told her she fell during Hoyer lift transfer the night before. CNA A reported to the charge nurse right away. She also stated if a resident required a Hoyer lift, there should always be two people assist with the transfer. During an interview on 2/7/24 at 2:05 p.m. with the Director of Nursing (DON), the DON stated the CNA was transferring Resident 1 with a Hoyer lift by herself, but she should have had another staff with her during the transfer, everybody knew that. The CNA also should have reported the incident as a fall. She further stated the facility didn ' t have a system on monitoring and changing the Hoyer lift pads prior to the incident. During an interview on 2/9/24 at 2:30 p.m. with Licensed Vocational Nurse (LVN) B, LVN B stated the CNA did not report the fall to her, the CNA only told her that Resident 1 ' s Hoyer lift pad strap was broken and she believe the CNA was alone during the transfer. The incident was considered a fall, and the CNA should have reported it to her. She further stated it was everybody ' s responsibility to make sure the equipment worked properly prior to the transfer. During a review of the facility ' s policy and procedure (P&P) titled Fall Precautions - Resident Care, revised December 2017, the P&P indicated, 1. The definitions cited below relate to this policy. 1.1 A Fall is defined as a sudden, involuntary and/or unanticipated drop to a lower position that may or may not result in a physical injury. During a review of the facility ' s P&P titled No-Lift Transfers, revised December 2017, the P&P indicated, 3. Various lifts are available for staff to use. 3.1 The sling lift is utilized for transferring a non-weight bearing resident who is largely bedridden from bed to chair and back. It offers full support for several positions from lying to sitting. [ .] 3.3 Two staff members are present whenever a lift is being used.

Based on interview and record review, the facility failed to provide the resident and /or their representative with a summary of the care plan for one of three sampled residents (Resident 1). This failure had the potential to limit communication concerning the resident's needs and development of a person-centered plan of care. Findings: A review of Resident 1's July 2023 clinical record, the clinical record indicated Resident 1 was admitted on [DATE] with diagnoses including malignant neoplasm of the endometrium (a type of cancer that starts in the lining of the uterus). During a concurrent interview and record review with the Nurse Supervisor (NS) on 8/15/2023 at 12:56 p.m., no document indicated that Resident 1 had received a summary of the baseline care plan. The NS reviewed Resident 1 clinical record and confirmed she did not see any documentation that Resident 1 had received the baseline care plan. The NS stated the licensed nurses should provide the baseline care plan to Resident 1 to sign and keep a copy in the clinical record. During an interview with the Director of Nursing (DON) on 8/15/2023 at 2:30 p.m., the DON acknowledged the licensed nurses should document that residents have received the copies after providing the summary of the baseline care plans to residents and/or their representatives. A review of the facility's policy and procedure (P&P) titled Resident Care, revised October 2017, the P&P indicated, The resident and their representative will be provided with a summary of the baseline care plan that includes: Initial goals of the resident; Summary of the resident's medications and dietary instructions; Any services and treatments to be administered; and Any updated information based upon the details of the comprehensive care plan, as necessary.

Based on observation, interview, and document review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There were unlabeled and undated food items in the kitchen refrigerator and blast chiller (equipment that quickly lowers food temperature); 2. There were dented cans of food in the dry storage area of the kitchen; 3. There was a black substance on the inside of one out of two ice machines; and 4. Kitchen attendant B (KA B) did not follow printed instructions when testing the surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to cause food contamination and illness for all residents who received food from the kitchen (34 of 35 residents). Findings: 1. During a kitchen observation on 3/13/23 at 9:13 a.m., accompanied by the executive chef (EC), the refrigerator designated for the skilled nursing facility (SNF) was inspected. There was one medium-sized metal container filled with a dark red liquid. The container was not labeled with any dates or the name of the food item. The EC confirmed this observation and stated he would discard the food item. During a kitchen observation on 3/13/23 at 9:15 a.m., accompanied by the EC, the blast chiller was inspected. There was one large pot filled with a thick, light brown sauce. The pot was not labeled with any dates or the name of the food item. The EC confirmed this observation and stated food items should be labeled with the date they were prepared so staff can tell how long the food items are good for. The EC further stated containers should be labeled with the name of the food item so staff can tell what the food item is. Review of the facility's policy titled Sanitation and Safety, revised 6/2011 indicated, Foods prepared on the premises to be held cold will be labeled with the name and the date of preparation. This food will also be labeled with the date to discard or 'use by.' The discard/use by date will be a maximum of 6 days after the preparation. 2. During a kitchen observation on 3/13/23 at 9:20 a.m., accompanied by the EC, there was one dented can of tomato paste and one dented can of coconut milk in the dry storage area. The dented cans were stored with the other cans of food that were meant to be prepared and consumed. The EC confirmed this observation and acknowledged the dented cans of food should have been stored in the area specifically designated for dented cans. Review of the United States Food and Drug Administration's 2022 Food Code indicated, pitted or dented cans may present a serious potential hazard. 3. During an observation and concurrent interview with the director of dining services (DDS) on 3/14/23 at 10:53 a.m., the ice machine in the SNF pantry (a small area of the SNF where food is stored and prepared) was inspected. The DDS opened the ice machine lid, then used a white paper towel to wipe several parts inside the ice machine that were directly above the ice. After wiping the inside of the ice machine, there were black substances on the white paper towel the DDS used to do the wiping. The DDS confirmed this observation. Review of the United States Food and Drug Administration's 2022 Food Code indicated, ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. The food code further indicated that food equipment, which includes ice makers, shall be clean to sight and touch. 4. During an observation on 3/15/23 at 1:53 p.m., kitchen attendant B (KA B) tested the surface sanitizer in the SNF pantry. KA B filled a small red bucket with the sanitizing solution, then pulled out a piece of test paper from its packaging. KA B dipped the test paper in the sanitizing solution for less than one second, immediately pulled it out, then checked to see if the test paper changed to the appropriate color. Review of the undated instructions on the test paper packaging indicated to dip the test paper in the sanitizing solution for 10 seconds. During an interview with KA B on 3/15/23 at 1:55 p.m., he acknowledged the instructions indicated to dip the test paper in the sanitizing solution for 10 seconds.

Based on interview and record review, the facility failed to implement the antibiotic stewardship program (program intended to prevent the overuse of antibiotics) for one of three sample residents (Resident 26). Resident 26 received a course of antibiotics, but did not meet the criteria for antibiotic treatment. This failure had the potential to increase the prevalence of multi-drug resistant organisms in the facility. Findings: Review of Resident 26's medical record indicated he was admitted on [DATE] and had a history of urinary tract infection (UTI) and long-term use of antibiotics. Further review of the medical record indicated Resident 26 did not have an indwelling catheter (flexible tube inserted and left in the bladder to drain urine). Review of Resident 26's Progress Notes, dated 1/29/23, indicated he had increased confusion. The notes further indicated Resident 26's physician ordered a urinalysis with culture and sensitivity (UA/C&S, a urine test to determine if bacteria is present and which antibiotics would be effective). Review of Resident 26's UA/C&S results, dated 1/30/23, indicated the presence of greater than 100,000 colony-forming units per milliliter (cfu/ml, unit of concentration measurement) of Escherichia coli (a type of bacteria). Further review of Resident 26's medical record indicated that aside from increased confusion and a positive UA/C&S result, there was no documentation of any other signs and symptoms of a UTI. Review of Resident 26's Prescription Order, dated 1/30/23, indicated to give Bactrim DS (an antibiotic) 800-160 milligrams (mg, unit of dose measurement) by mouth every 12 hours for 14 days for UTI. Review of Resident 26's document titled Infection Control -- Infection Tracker with McGeer's Criteria [tool used to determine if the resident meets criteria for antibiotic treatment], dated 1/30/23 indicated, Does NOT meet McGeer's criteria for UTI. During an interview and concurrent record review with the director of staff development (DSD) on 3/16/23 at 4:48 p.m., he confirmed the facility used McGeer's criteria to determine if residents met the criteria for antibiotic treatment. The DSD explained if a resident was taking antibiotics and the facility determined the criteria were not met, the nurse should contact the physician to see if the antibiotic can be discontinued. The DSD stated if the physician chooses to continue the antibiotic, the nurse should document that the physician was informed and declined to discontinue the antibiotic. The DSD reviewed Resident 26's medical record and confirmed the documentation only indicated increased confusion and a positive UA/C&S result. The DSD acknowledged these two signs and symptoms alone did not meet the criteria for antibiotic treatment for UTI. The DSD also confirmed there was no documentation indicating the physician was notified that Resident 26 did not meet the criteria and declined to discontinue the antibiotic. Review of Resident 26's medication administration record (MAR) indicated he received the full course of Bactrim DS 800-160 mg every 12 hours, from 1/30/23 to 2/13/23. Review of the Revised McGeer Criteria for Urinary Tract Infection Surveillance Checklist, dated 2012, indicated that without an indwelling catheter, a person with the combination of increased confusion and a positive UA/C&S result alone does not meet the criteria for antibiotic treatment for UTI.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for two of 12 sampled residents (Resident 5 and 24) when: 1.The licensed nurse irrigated the left and right nephrostomy (an artificial opening created between the kidneys and the skin to facilitate urine drainage) tubes with one syringe; and 2.The licensed nurse did not perform hand hygiene between tasks. These failures had the potential for the development and the spread of infections in the facility. Findings: 1. A review of the Resident 24's physician orders indicated Resident 24 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the prostate (Cancer in a man's prostate), urinary tract infection(an infection in any part of the urinary system), streptococcal infection (a type of bacteria that can cause skin, soft tissue, and respiratory tract infections), and artificial openings of urinary tract status-Nephrostomy status. During a concurrent observation and interview on 3/15/23 at 11:13 a.m., in Resident 24's room, Registered Nurse (RN) D irrigated the left nephrostomy tube with normal saline (NS), then she used the same syringe to aspirate 10 milliliter (ml-unit of liquid measurement) NS from the NS bottle and irrigated the right nephrostomy tube. RN D verified that she did not change the syringe in between the irrigations and she further stated using one syringe for both tubes could increase the risk of infection. During an interview with the Director of Nursing (DON) on 3/16/23 at 4:30 p.m., the DON stated that the RN should not use one syringe to flush both nephrostomy tubes. She further stated the licensed nurse should have used two NS syringes to flush each tube to prevent infections. A review of the facility's undated competency skill checklist titled intermittent irrigation-nephrostomy tube indicated adhere to strict aseptic technique to irrigate the nephrostomy tubes. 46553 2. During a medication administration observation with Licensed Vocational Nurse C (LVN C) on 3/13/23 at 11:10 a.m., in Resident 5's room, LVN C did not wash or sanitize her hands before and after administering the oral medications to Resident 5. During a concurrent observation and interview on 3/13/23, at 11:10 a.m., LVN C confirmed the above observation and further stated she should have sanitized her hands before and after administering medications. During an interview with the DON on 3/17/23 at 10:36 a.m., the DON stated staff should wash or sanitize their hands before and after entering residents' rooms, before administering medications, between tasks, and between changing gloves. Review of the facility's policy and procedure titled Hand Hygiene revised August 2018 indicated, Hand antisepsis should be performed before and after resident contact.

Based on observation, interview, and record review, the facility failed to administer oxygen in accordance with professional standards of practice for one of two sampled residents (Resident 5), when her oxygen humidifier bottle (a bottle filled with water connected to the oxygen source to keep the airways moist) was empty and oxygen humidifier bottle was not changed weekly. These failures had the potential to affect the residents' health and safety. Findings: Review of Resident 5's clinical record indicated she was admitted to the facility on [DATE] with diagnoses including idiopathic sleep related nonobstructive alveolar hypoventilation (a rare disorder in which a person does not take enough breaths per minute), sleep-related hypoxia (low levels of oxygen in the body tissues), and hypoxemia (when oxygen levels in the blood are lower than normal). Review of Resident 5's clinical record indicated she had a physician's order, dated 2/22/23, to administer oxygen at 2 - 5 liters per minute (LPM, oxygen flow rate) via nasal cannula (NC, flexible tubing that is placed in the nostrils and attached to an oxygen source), titrate (adjust) for comfort. During an observation on 3/13/23 at 10:57 a.m., Resident 5 was lying in bed receiving oxygen at 2 LPM via NC. The humidifier bottle attached to the oxygen concentrator (a machine that supplies oxygen) did not have any water inside. In addition, the humidifier bottle was dated 3/3/23 (10 days prior to this observation). During a concurrent observation and interview on 3/13/23, at 11:26 a.m., with licensed vocational nurse C (LVN C), LVN C verified the oxygen humidifier bottle was empty and dated 3/3/23. LVN C stated the humidifier bottle needed to be changed every seven days and as needed by the night shift. During a concurrent interview and record review with the director of nursing (DON), on 3/17/23, at 10:36 a.m., the DON stated licensed nurses should ensure that the humidifier bottle is cleaned and changed when it is empty or if the water level is low. The DON verified the humidifier bottle should be changed every seven days by the night shift.

Based on interview and record review, the facility failed to provide and/or document restorative nursing assistant (RNA) treatments for one of five sampled residents (Resident 26). This failure had the potential to result in functional decline for Resident 26. Findings: Review of Resident 26's medical record indicated he was admitted on [DATE] and had the diagnoses of atrial flutter (a condition in which the upper chambers of the heart beat too quickly), chronic obstructive pulmonary disease (COPD, a condition of the airways that causes difficulty breathing), and Parkinson's Disease (a nervous system disease that causes muscle rigidity and tremors). During an interview with Resident 26's family member (FM) on 3/14/23 at 12:34 p.m., the FM stated staff have provided Resident 26 with RNA treatments, but the treatments were sporadic. Review of Resident 26's Order History indicated he had a physician's order for RNA treatments from 9/15/22 to 12/15/22. The order indicated the RNA was to ambulate (walk) Resident 26 in the hallway and perform active range of motion exercises (activity meant to improve joint movement) to both arms and both legs for 15 to 30 minutes, three to five times a week. During an interview with restorative nursing assistant A (RNA A) on 3/15/23 at 8:53 a.m., she stated that when she performs RNA treatments with a resident, she must document the treatments in the electronic health record (EHR). RNA A further stated that if a resident refuses an RNA treatment, she must still document in the EHR and indicate that the resident refused. Review of Resident 26's Point of Care History, dated 9/15/22 to 12/15/22, indicated there were five weeks for which there was no documentation that RNA treatments were either provided as ordered or refused. During an interview and concurrent record review with the director of nursing (DON) on 3/16/23 at 3:52 p.m., the DON reviewed Resident 26's medical record and acknowledged there were several weeks for which there was no documentation that RNA was either provided as ordered or refused. The DON stated, If it's not documented, it was not done. Review of the facility's document titled Restorative Care Protocol, revised 10/2017, indicated RNA responsibilities include providing restorative treatments to assigned residents and documenting daily on the designated flow sheets, including dates of treatment and number of minutes for each treatment.

Based on interview and record review, the facility failed to ensure one sampled resident (1) received supervision during meals. This failure resulted in Resident 1 sustaining a burn (damage to the skin or deeper tissues caused by sun, hot liquids, fire, electricity, or chemicals) after spilling a hot beverage on her chest. Findings: Review of Resident 1's clinical record indicated she was admitted with a diagnoses including acute respiratory failure (ARF, a problem getting gases in and out of the blood). Review of Resident 1's progress notes dated 6/8/21, indicated [Resident 1] asked a staff to reheat her tea, the staff reheated the tea, [Resident 1] accidentally spilled her tea on her mid chest area. Redness noted, c/o [complaint of] of mild pain .affected skin area measured 7 centimeter [cm, a type of unit measurement] x 3cm . Review of the facility's final report for event investigation received by the California Department of Public Health (CDPH) on 7/15/21, indicated when [Resident 1] took a sip, the tea was boiling and spilled on [Resident 1's] front. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/30/21, indicated she was cognitively intact and needed supervision with one person physical assistance while eating. During an interview with the registered nurse A (RN A) on 12/2/21 at 12:30 p.m., she stated Resident 1 called the attention of the certified nursing assistant (CNA) to report what happened on 6/8/21. During a follow up interview and concurrent record review with RN A on 12/2/21, she stated Resident 1 was alert and did not need supervision during meals. During an interview with licensed vocational nurse (LVN) B on 12/2/21 at 12:45 p.m., she stated Resident 1 is alert, has oxygen (a colorless and odorless gas that people need to breathe), and has periods of shaking but did not need supervision while eating. During an interview with the director of nursing (DON) on 12/2/21 at 2:40 p.m., the DON acknowledged Resident 1 should have been supervised during meal as indicated in Resident 1's MDS. Review of the facility's policy Resident Care, revised on 12/2017, indicated care provided to the residents in SN (skilled nursing) includes assistance with activities of daily living including eating, meal service and assistance with eating.

Based on interview and record review, the facility failed to follow their policy and plan of care for one of three sampled residents (1). On 5/9/18 Resident 1 was transferred using a Hoyer lift (equipment used to transfer residents using a sling) with only one staff. This failure resulted in Resident 1's fall, hospitalization , left humerus fracture (broken bone in the left upper arm), subdural hemorrhage (bleeding into the space directly outside the brain), subarachnoid hemorrhage (bleeding into the protective lining surrounding the brain), intraparenchymal hemorrhage (bleeding within the brain), and [MEDICAL CONDITION] (bleeding inside the skull). Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE] and had the [DIAGNOSES REDACTED]. A fall risk assessment tool, dated 3/20/18, indicated Resident 1 was at high risk for falls. A Minimum Data Set (MDS, an assessment tool), dated 3/20/18, indicated Resident 1 required extensive assistance (staff provide weight-bearing support) from two or more people for transfers. A risk for falls care plan edited on 3/21/18, indicated Resident 1 required Hoyer lift transfers for safety. A decreased functional mobility care plan edited on 3/21/18, indicated Resident 1 required a Hoyer lift and maximum assistance from two people for transfers. A progress note dated 5/9/18, indicated Resident 1 took a fall in his room during transfer. The progress note further indicated Resident 1 complained of pain in his left arm and the facility sent him to the acute hospital for evaluation. During an interview with the director of nursing (DON) on 5/11/18 at 1:20 p.m., she confirmed certified nursing assistant A (CNA A) was the one who transfered Resident 1 when he fell on [DATE]. The DON explained she did not witness the fall herself, but she received a statement from CNA A about what happened. According to the DON, CNA A stated she put the sling underneath Resident 1 while he was in bed and attached the sling to the Hoyer lift. The legs of the Hoyer lift got stuck underneath Resident 1's bed and CNA A tried to pull the lift to free the legs, but was unsuccessful. CNA A used the bed controls to raise Resident 1's bed so she could free the legs of the Hoyer lift. As CNA A was raising the bed, the Hoyer lift tipped over and Resident 1 fell to the floor. The DON confirmed CNA A used the Hoyer lift without assistance from another staff member. A post-fall assessment dated [DATE] indicated when Resident 1 fell on [DATE], he hit his head and complained of severe pain in his left arm. The post-assessment further indicated, Staff person was transferring resident alone. Review of a discharge summary from the acute hospital dated 5/9/18 to 5/14/18 indicated Resident 1 arrived at the hospital after falling while being lifted at the facility. Resident 1 was found to have a [MEDICAL CONDITION] humerus, a subarachnoid hemorrhage, and a subdural hemorrhage. During an interview with CNA B on 5/11/18 at 2:45 p.m., she stated the facility has conducted in-services (training sessions) on proper use of the Hoyer lift in the past. CNA B stated two staff members must be present at all times when the Hoyer lift is being used. CNA B stated, I cannot touch the patient until another person is there to help. During an interview with the director of rehab (DOR), on 5/11/18 at 2:58 p.m., she stated, It's a must that Hoyer lift transfers be performed by two people. The DOR stated two people must be present from the beginning to the end of a Hoyer lift transfer. During an interview with licensed vocational nurse C (LVN C) on 5/15/18 at 11:31 a.m., she confirmed she was the nurse in charge of Resident 1 when he fell on [DATE]. LVN C stated she heard CNA A call for help and ran to Resident 1's room. LVN C stated she saw Resident 1 on the floor with the sling still underneath his body and attached to the Hoyer lift. LVN C confirmed CNA A was the only staff member in Resident 1's room during the time of the incident. LVN C acknowledged two staff members must be present at all times when a Hoyer lift is being used. An In-service Cover Sheet, dated 1/6/17, indicated the facility conducted a lecture, discussion and demonstration on how to properly use a Hoyer lift. The cover sheet indicated, Two persons to use Hoyer lift. A sign-in sheet dated 1/6/17, indicated CNA A attended this in-service. A personnel file review indicated CNA A also completed training on lifting and transferring residents on 3/14/14, 6/5/15, 9/21/16, and 10/7/17. Review of a letter from the facility to California Department of Public Health, dated 5/14/18, indicated Resident 1 received injuries during a transfer from his bed to the wheelchair. The CNA was transferring the resident unassisted. The legs of the lift were caught under the bed and when the CNA attempted to free the lift, it became off balance and tipped to the side causing the resident to fall to the floor while in the sling. The facility's policy,No-Lift Transfers, revised 6/2012, indicated, Two staff members are present whenever a lift is being used. Resident 1's clinical record indicated he returned to the facility on [DATE]. A physical therapy assessment dated [DATE], indicated Resident 1 had a plaster slab splint on his left arm and complained of severe pain on lt UE (left upper extremity) on movement. A progress note, dated 5/18/18, indicated Resident 1 had blood in his urine, an elevated temperature and elevated heart rate. The progress note indicated the facility called 911 and paramedics took the resident back to the acute hospital. Review of an Emergency Department Provider Note dated 5/18/18, indicated Multiple critical illnesses, specifically severe [MEDICAL CONDITION] requiring blood transfusion, [MEDICAL CONDITION] from a likely urinary source, and critical [DIAGNOSES REDACTED] (low potassium) and [DIAGNOSES REDACTED] (low calcium) .Subarachnoid hemorrhage . Review of an Internal Medicine Progress Note dated 5/19/18 indicated, worsening [MEDICAL CONDITION] and labs showing UTI (urinary tract infection) .Sepsis .will treat with only comfort measures. Review of a discharge summary from the acute hospital, dated 5/18/18 to 5/21/18, indicated Resident 1 presented to the hospital with decreased alertness and fever. A computerized tomography scan (CT scan, procedure used to view internal components of the body) showed a subdural hematoma and intraparenchymal hemorrhage with new midline shift (shift of the brain past its central line). The discharge summary indicated Resident 1 passed away on 5/21/18. The discharge summary stated the principal [DIAGNOSES REDACTED]. The discharge summary stated Resident 1 also had a positive urine culture (bacteria growing in his urine), but antibiotics were held.