Artesia Christian Home Inc.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Food storage was not maintained under sanitary conditions when surveyors observed multiple unlabeled food items in the facility kitchen refrigerator. During a concurrent observation and interview on 1/20/2026 at 8:16 a.m., an opened bag of raw chicken was seen on a tray without a date, and CK 1 stated it should have been dated. During another observation and interview on 1/20/2026 at 8:20 a.m., trays of raw ground beef, pork loin, pork, and chicken were observed unlabeled without dates in the refrigerator, along with a packaged container of green salad that also had no date on it. CK 1 stated the food items should have been labeled. During an interview on 1/22/2026 at 9:48 a.m., the RD stated raw meat and prepared foods need to be labeled with a date for resident safety. Review of the facility's Food Handling Guidelines, revised 1/2021, indicated thawing frozen meat and poultry under refrigeration need to be labeled with the date removed from the freezer and the date by which it must be used. Review of the Food and Supply Storage policy, revised 1/2021, indicated all food items shall be stored to maintain safety and wholesomeness of food for human consumption, and unused portions and open packages are to be covered, labeled, and dated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Hand hygiene was not performed before staff entered resident rooms during medication preparation and resident care. After preparing medications for Resident 16, an LVN entered Resident 30's room without performing hand hygiene. In a separate observation, another LVN prepared Resident 30's medication and then entered the resident's room without performing hand hygiene. The DON stated hand hygiene should be performed when hands are visibly soiled, contaminated, or before going into a resident's room, and the facility's hand hygiene policy identified hand hygiene as the primary means to prevent the spread of infections. Enhanced Barrier Precautions were not followed for a resident with an indwelling foley catheter. Resident 8 had an order for EBP due to the catheter. During an observed ROM session, RNA 2 entered the resident's room, put on gloves, and physically assisted the resident with ROM exercises to both shoulders, elbows, hands, and knees without wearing an isolation gown. RNA 2 confirmed the gown was not worn even though direct contact occurred during the care activity. The ADON, IPN, and DON stated staff providing direct care to residents on EBP, including ROM assistance, must wear an isolation gown and gloves, and the facility's EBP policy described targeted gown and glove use during high contact resident care activities. Shared equipment was not disinfected according to manufacturer instructions. In the therapy gym, COTA 1 used a cloth gait belt with Resident 54 during therapy activities and then wiped both sides of the gait belt with disinfectant wipes after the session. The DOR reviewed the wipe instructions and confirmed they were for hard, non-porous surfaces only, while the gait belt was made of fabric and porous material. The DOR stated the wipes were ineffective for the cloth gait belt and that laundering after each resident use was the only way to effectively clean and disinfect it. The facility's policy required reusable resident care equipment to be cleaned and disinfected according to manufacturer instructions, and the Lysol wipe policy stated the wipes could not be used on porous surfaces. The facility also did not follow its water testing policy and procedure. During review of the water testing policy and 2025 water temperature logs, the DC stated there was no documentation showing water heater temperatures were checked monthly as required by the policy. The DC also stated they did not know when the Water Testing policy was last reviewed or revised. The DON stated water testing is important to prevent residents from contracting legionnaires disease and that the Water Testing policy should be reviewed at least annually to reflect current guidance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure oral medications were not crushed and administered together for two residents. Resident 16 was admitted with diagnoses including dementia, Alzheimer’s disease, and atherosclerotic heart disease, and the record showed the resident lacked capacity to understand and make decisions, had severely impaired cognitive skills, and was dependent for all activities of daily living. The physician orders included a directive to crush all crushable medications, along with aspirin chewable 81 mg daily and a multivitamin daily. During a concurrent observation and interview, an LVN was observed crushing the multivitamin and aspirin together and mixing both crushed medications with applesauce before giving them to Resident 16. The LVN stated it was acceptable to crush the medications together and that doing so would not affect the resident. Resident 31 was readmitted with diagnoses including major depressive disorder, anxiety disorder, and osteoarthritis, and the MDS indicated severely impaired cognitive skills for daily decision-making and the need for set up or clean up assistance with eating. The physician orders included a directive to crush all crushable medications, loratadine 10 mg daily, Tylenol 325 mg two tablets daily, and Seroquel 25 mg twice daily. During a concurrent observation and interview, an LVN placed loratadine, Tylenol, and Seroquel in a pill crusher pouch and crushed the pills together for administration to Resident 31, stating the pills were crushed to make it easier for the resident. The DON later stated the facility pharmacy policy and procedure on crushing medications indicated residents shall not receive crushed medications combined and given all at once orally.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care to maintain and/or improve ROM for three residents with ROM concerns. For one resident with diagnoses including cellulitis of both legs, muscle weakness, and sepsis, the PT evaluation dated 12/23/2025 identified impaired ROM in both legs, but the evaluation did not objectively measure the limitations or identify which joints were affected. During observation, the resident was sitting in a wheelchair, minimally bent both hips, was unable to straighten both knees, and minimally bent and straightened both ankles. The DOR confirmed the PT did not use a goniometer and stated the baseline ROM of both legs was not determined because the limitations were not measured. For another resident with diagnoses including rheumatoid arthritis, gastrointestinal hemorrhage, and muscle weakness, the OT evaluation dated 10/3/2025 identified impaired ROM in both shoulders and both hands, but the evaluation did not objectively measure those limitations or identify the severity of the impairment. During observation, the resident’s knuckles were swollen, all fingers were bent downward and sideways toward the small fingers, and the resident was unable to straighten several fingers on both hands. The DOR and OT both confirmed that goniometer measurements were not taken for the affected shoulders and hands, and stated the resident’s baseline ROM was not determined because the limitations were not measured. The facility also failed to carry out restorative nursing services as ordered. One resident with diagnoses including dementia, a left femur fracture, and prostate cancer had an RNA order for AAROM to both arms and both legs at least 5 times per week while observing left hip precautions. During an observed RNA session, the RNA physically assisted some movements of the resident’s arms and knees, but did not provide ROM to both wrists, both hips, or both ankles, and did not provide the ordered exercises in the manner described by the RNA order. Another resident with rheumatoid arthritis and muscle weakness had a physician’s order for RNA to assist with ambulation exercises using a front wheeled walker at least 5 times per week. The RNA history reports showed multiple missing care records and dates when the task was not performed, and the DSD confirmed the resident missed 13 RNA sessions from 12/1/2025 to 1/23/2026.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Restorative Nursing Aides (RNAs) were competent to provide restorative nursing services to a resident with dementia, a left femur fracture, and a history of left hip surgery. The resident had physician orders for weight bearing as tolerated to the left leg with posterior hip precautions and an RNA order for active assistive range of motion (AAROM) to both arms and both legs at least five times per week while observing left hip precautions. The resident’s Minimum Data Set showed severely impaired cognition and dependence or substantial/maximal assistance for multiple activities of daily living. During an observed RNA session, one RNA transported the resident to the room and positioned the wheelchair next to the bed. One RNA physically raised and lowered both arms to shoulder height, bent and straightened both elbows, and bent, straightened, and spread the fingers of both hands eight times each, but did not assist or cue wrist ROM. The other RNA asked the resident to march in place, observed minimal movement of both thighs, did not assist with hip ROM, physically assisted both knees through flexion and extension eight times each, and did not provide or cue ankle ROM. The resident was then returned to the dining room. In interviews, both RNAs stated they did not know what left hip precautions meant and had not been instructed by therapy on those precautions. One RNA stated she believed she was providing AAROM by giving verbal cueing only and acknowledged she had provided PROM to several joints even though the order was for AAROM. Both RNAs stated they had been providing ROM services without understanding the hip precautions and admitted they had not asked for clarification. The Director of Rehabilitation stated AAROM to both legs should include the hips, knees, and ankles, and AAROM to both arms should include the shoulders, elbows, wrists, and hands. The DON and DSD stated the facility did not conduct RNA competencies and therefore did not have a way to ensure RNA staff were competent in their job duties.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer psychotropic medications in a timely manner for one of four sampled residents, Resident 39. Resident 39 was admitted and later readmitted with diagnoses including unspecified dementia with agitation and psychotic disturbance, anxiety disorder, and Parkinsonism. The H&P stated the resident did not have the capacity to understand or make decisions, and the MDS indicated severely impaired cognitive skills and dependence on staff for all ADLs. Physician orders included Seroquel 100 mg twice daily for dementia with psychosis manifested by resisting care and continuous yelling out, and Sertraline 50 mg daily for anxiety manifested by yelling behavior. The Psychotropic Administration History showed multiple late administrations of both medications, including doses given at 10:41 a.m., 11:59 a.m., 10:29 a.m., and 11:06 a.m. instead of the scheduled 9:00 a.m. times. During interview and record review, the LVN stated medications are administered one hour before and after the scheduled time, acknowledged the doses given at 10:29 a.m. were late, and stated she could not get to the resident on time all the time. The DON also stated the Seroquel and Sertraline were administered late and that medications should not be given two hours later than scheduled. The facility policy stated medications must be administered in a safe and timely manner and within one hour of the prescribed time unless otherwise specified.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain accurate medical records for two residents by not documenting restorative nursing aide (RNA) services as required and by leaving an outdated hip precaution on an RNA order after the physician had discontinued the precaution. The report states that these deficiencies were identified through observation, interview, and record review and involved Resident 2 and Resident 8. For Resident 2, the record showed an admission and readmission with diagnoses including rheumatoid arthritis, gastrointestinal hemorrhage, and muscle weakness. A physician order dated 12/15/2025 directed RNA to assist with ambulation exercises using a front wheeled walker at least 5 times per week. The December 2025 RNA History Report and January 2026 RNA History Report both showed multiple missing care records for scheduled walking exercises. The resident’s MDS dated 1/14/2026 indicated cognitive intactness, need for assistance with multiple activities of daily living, and functional limitations in ROM in both arms and both legs. During interview, Resident 2 stated she had right knee pain from rheumatoid arthritis, could not walk by herself, and wanted RNA to come more often to walk her to and from the dining room. RNA staff stated they were supposed to document services after every session, but also stated that if they were unable to provide the scheduled RNA exercises, they would not document anything in the electronic record. For Resident 8, the record showed diagnoses including dementia and a left femur fracture. The physician order report showed a prior order for WBAT to the left leg with posterior hip precautions that was discontinued on 4/2/2025, and an RNA order dated 6/6/2026 that still directed RNA to provide AAROM to both arms and both legs while observing left hip precautions. During an RNA session observation, RNA staff performed arm ROM, had the resident march both legs in place, assisted with knee flexion and extension, and did not provide hip ROM or ankle ROM exercises. The DOR confirmed that the RNA order was inaccurate because the left hip precautions had already been discontinued by the physician, and stated staff should have discontinued the precautions on the RNA order when the physician discontinued them. The facility policy required documentation to be objective, completed, and accurate.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide documented evidence of COVID-19 education and vaccination status for four of four sampled employee records: CNA1, CNA2, FSW, and LS. During interview and record review with the ADON, the facility’s employee records for COVID-19 immunization were reviewed, and the ADON stated the status was unknown for all four sampled staff members. During interview and record review with the IPN, the County of Los Angeles Department of Public Health order regarding annual influenza and COVID-19 immunization or masking requirements for healthcare personnel during respiratory virus season was reviewed. The order stated that healthcare providers who decline influenza or COVID-19 vaccination must provide a written declaration for each vaccine declined on a form provided by the employer. The ADON stated that most staff had not replied whether they accept or decline vaccinations. During interview with the DON, the DON stated the facility needed employees’ COVID vaccination status updated. The facility’s undated policy titled COVID-19 Vaccination stated that the person receiving the immunization, or his/her legal representative, would be provided a copy of the current vaccine information statement relative to COVID-19 vaccination.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure one of one sampled residents, Resident 45, was treated with respect and dignity when a clear trash bag was placed on the resident's bed during a wound treatment. During an observation on 1/22/2026 at 9:33 a.m., the Treatment Nurse was seen placing the bag on the bed and disposing of gauze, gloves, and a medicine cup into it while providing the treatment. Resident 45's record showed diagnoses including dementia, benign prostatic hyperplasia, and a suprapubic catheter. The admission record and H&P indicated the resident did not have the capacity to understand and make decisions, and the MDS dated 10/21/2025 indicated severe cognitive impairment and dependence for eating, oral hygiene, toileting hygiene, bathing, and dressing. The Treatment Nurse stated the bag was placed on the bed because there was no trash can in the room, and the DON stated trash bags should not be placed on residents' beds during treatment because it could make a resident feel not respected or cared for in a respectful way.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an Advance Directive was formulated for one resident, Resident 26. The resident was admitted with diagnoses including unspecified dementia, hypertension, and hypertrophic lichen planus. The admission record and subsequent H&P indicated the resident did not have the capacity to make healthcare decisions, and the MDS showed severely impaired cognitive skills and dependence for activities of daily living. During interview, the SSD stated an AD is offered upon admission and that Resident 26 did not have one. The SSD also stated an AD helps identify what decisions or wishes a resident would like to have for medical care and is important so the family is aware of who the resident would want to make healthcare decisions. The DON stated an AD reflects the resident's decisions regarding care they wish to receive or decline and that it was important to ask the resident if he would like to formulate an advance directive and provide education and information. The facility policy stated residents are to be provided written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive upon admission, or the legal representative if the resident is incapacitated.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the physician when Resident 45’s pressure injury progressed from a stage 1 to a stage 2 on the sacrum. Resident 45 was admitted with diagnoses including dementia, benign prostatic hyperplasia, and a suprapubic catheter. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severe cognitive impairment with dependence for eating, oral hygiene, toileting hygiene, bathing, and dressing. During record review and interview with the TXN, Resident 45’s nursing note documented a stage 1 pressure injury on the sacrum, followed the next day by a stage 2 pressure injury on the sacrum. The TXN stated there was no documentation that the RN notified the physician when the wound worsened, and stated the physician should have been notified when it progressed. The DON stated the nurse should notify the physician when there is a change of condition and document it as a progress note, and that failure to notify the physician created a risk that the resident’s wound would not be treated appropriately to promote healing.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to verify the dose of Vitamin B-12 for one resident. Resident 35 was admitted with diagnoses including anemia, osteoarthritis, and osteopenia. The resident's MDS dated 10/16/2025 indicated cognitive skills for daily decision-making were intact. A review of the resident's View Prescription Order, starting 7/7/2023, showed Vitamin B-12 1,000 microgram (mcg) tablet once daily. During a concurrent interview and record review on 1/21/2026, the ADON reviewed the physician order and stated the order needed to be clarified because the tablet was 1,000 milligrams (mg) and the order indicated 1000 mcg, and that it was important to administer the correct dosage for resident safety. The DON later stated medication orders need to have the correct dosage. The facility's medication administration policy stated medications shall be administered in a safe manner with the right dose, and the pharmacy policy stated medication orders must be complete and clear and include the dose.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

An opened Tuberculin Purified Protein Derivative (PPD) vial in the North station medication room was observed during a concurrent observation and interview with the Registered Nurse Supervisor and was not labeled with the date it was opened. The RNS stated the vial should have had the open date on it, and during the same review of the vial carton, stated the package indicated the opened vial should be discarded after 30 days. The Director of Nursing later stated that PPD vials should be discarded 30 days after opening. Facility policy titled Medication Labeling and Proper Storage stated an opened Tuberculin PPD vial should be discarded after one month of use because oxidation and degradation may reduce potency, and the policy titled Administering Medication stated that when opening a multidose container, the date opened shall be recorded on the container.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure Physical Therapy and Occupational Therapy evaluations were completed under the written order of a physician for one resident. The resident was admitted on 9/1/2025 and re-admitted on 12/22/2025 with diagnoses including cellulitis of both legs, muscle weakness, and sepsis. The resident’s PT evaluation on 12/23/2025 identified decreased functional mobility, range of motion, strength, postural alignment, ambulation, balance, and activities of daily living, and planned PT services five times a week for 30 days. The OT evaluation on 12/23/2025 identified edema exacerbation, decreased strength, decreased ROM, wounds, and increased need for assistance, and planned OT services five times a week for 30 days. The resident’s PT discharge summary and OT discharge summary both indicated discharge from therapy services on 1/9/2026. The resident’s MDS dated 1/11/2026 showed moderately impaired cognition and dependence or need for assistance with multiple ADLs, including eating, oral hygiene, upper and lower body dressing, rolling, transfers, and bathing. During concurrent record review and interview on 1/22/2026, the DOR, who was a PT, reviewed the physician orders and confirmed PT and OT did not have physician orders to evaluate and treat the resident. The DOR also reviewed the therapy and clinical records and confirmed PT and OT evaluated the resident for skilled therapy services and provided treatment five times a week until discharge without a physician’s order. The DOR stated physician orders were required to ensure the resident was medically stable and appropriate to participate in therapy and to ensure the plan of care was developed in conjunction with the physician. The DON also stated PT and OT required physician orders to evaluate and provide therapy to residents to ensure the physician was aware of the plan of care and that residents were appropriate to participate in therapy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that six of twelve resident rooms measured at least 80 square feet per resident. During observation, interview, and record review, surveyors found that the affected rooms included two 4-bed rooms measuring 305.5 square feet each and four 2-bed rooms measuring 151 to 152 square feet each. During an interview with the Administrator, it was stated that the residents in the affected rooms were not negatively impacted, that there was sufficient room for nursing services for these residents, and that the rooms had been approved during OSHPD inspection. A letter dated 1/20/2026 showed the Administrator requested a room waiver for six of 18 rooms with sizes less than 80 square feet per resident. During the survey period, observations in the rooms showed residents had access in and out of the rooms, space for their furniture, and no problems with staff being able to administer or assist with care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report a suspected scabies outbreak involving three residents to the California Department of Public Health (CDPH) as required. Record reviews showed that all three residents had severe cognitive impairment and were dependent on staff for hygiene and bathing. Physician orders for these residents included the administration of Permethrin cream and Ivermectin for suspected or suspicious scabies, indicating clinical suspicion of an outbreak. Despite these findings, there was no evidence that the facility reported the suspected outbreak to CDPH within the required timeframe. Interviews revealed that the Infection Prevention Nurse was unaware of the requirement to report a suspected scabies outbreak to CDPH. The Director of Nursing stated that the IP nurse believed the Public Health Nurse would make the report, which led to the failure to notify CDPH. A review of the facility's policy indicated that outbreaks of communicable diseases must be reported to the appropriate agency within 24 hours, but this protocol was not followed in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that one of three sampled residents had personal belongings kept safe, resulting in the resident’s jewelry being lost. Resident 1 was admitted with diagnoses including dementia, GERD, and anemia. The resident’s MDS dated 10/2/2025 indicated moderately impaired cognition and that the resident needed set-up assistance when eating. During interview and record review, the Associate Director of Social Services reviewed Resident 1’s Resident Inventory List, signed and dated 6/20/2023, which listed a necklace with a heart [NAME]. The ADSS stated the necklace was lost and that it had sentimental value because the resident had worn it since graduating from high school. The ADSS stated residents should not lose their personal belongings in the facility. The facility policy titled Theft and Loss stated the facility was to protect and safeguard residents’ belongings, and the Resident Rights policy stated residents have the right to retain and use personal possessions to the maximum extent that space and safety permit.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve requested menu items to one of three sampled residents. Resident 1 was admitted with diagnoses including dementia, GERD, and anemia. The MDS dated 10/2/2025 indicated moderately impaired cognition and that the resident needed set-up assistance when eating. The general order dated 9/18/2023 indicated a Regular Diet, ground meat only with thin liquids. During a concurrent observation and interview on 11/26/2025 at 12:16 p.m. in the dining room, the Director of Staff Development observed that Resident 1 did not have coleslaw or roasted vegetables on the plate. The resident’s diet ticket printed at 11:51 a.m. that day listed Jicama Coleslaw and Balsamic Oregano roasted Vegetables. The DSD stated staff ask residents what they want to eat, the preferences are indicated on the diet tickets, and the resident should have been served coleslaw and roasted vegetables. The Registered Dietician also stated that food items on the diet ticket reflect resident preferences and need to be served to the residents. The facility policy titled Resident Meal Service stated residents will be offered menu choices for all meals, beverages, and snacks based on prescribed diet and food preferences, and that the menu served will honor residents’ rights.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to assess and report a significant change in a resident's condition after a left arm bruise was observed and reported to a licensed nurse. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with a pre-existing bruise on the left arm. Over time, the bruise increased in size, and on the day in question, a certified nurse assistant noticed the resident protecting her arm and observed a large purplish bruise, which was reported to the licensed vocational nurse (LVN). The LVN, upon being informed, checked the resident's chart and noted the bruise had been documented at admission but did not physically assess the resident. The LVN instructed the CNA to notify the treatment nurse. The treatment nurse, a registered nurse (RN), also reviewed the chart and did not assess the resident's arm, believing it was not a change in condition. Both the LVN and RN acknowledged during interviews that an assessment should have been performed to determine if there were any changes to the resident's skin or condition. Subsequently, the resident was found to have an acute fracture of the left humerus, as indicated by a radiology report. The facility's policies required prompt assessment and notification of changes in a resident's condition, including new or worsening injuries. The failure of staff to assess and report the change in the resident's arm condition resulted in a delay of care and was identified as a deficiency during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was properly assessed and evaluated after an unwitnessed fall, which occurred on 12/7/2024. The resident, who had a history of falls and severe cognitive impairment, was given a Dulcolax suppository and was not adequately monitored afterward. Despite having a pressure pad alarm in place, the resident was found on the floor with multiple skin tears on the left forearm after attempting to get up without assistance. Interviews with staff revealed that the resident was known to be impulsive and did not use the call light, and it was acknowledged that residents should be checked every 30 minutes after receiving a suppository to prevent falls. The Assistant Director of Nurses (ADON) and the Director of Nurses (DON) both confirmed that a fall risk evaluation was not conducted after the resident's fall on 12/7/2024, which is a critical step in assessing changes in the resident's condition and updating the care plan. The facility's policy on falls and fall risk management emphasizes the importance of identifying interventions based on evaluations to prevent falls and minimize complications. The lack of a fall risk evaluation and inadequate supervision after administering a suppository contributed to the resident's fall and subsequent injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the consulting pharmacist conducted monthly and as-needed Drug Regimen Reviews (DRR) and made recommendations for Gradual Dose Reductions (GDR) or medication dosage adjustments for residents receiving psychotropic medications. This deficiency was identified for two residents with dementia and 23 other residents receiving psychotropic medications. The facility did not ensure that these residents were not receiving duplicate therapy or unnecessary medications, which placed them at high risk for potential side effects and uncontrolled behavioral symptoms. Resident 17 was admitted with diagnoses including dementia, bipolar disorder, and major depressive disorder. The resident was on multiple psychotropic medications, including Cymbalta, Ativan, Seroquel, and Depakote. Despite being on these medications, there was no documentation of a DRR or GDR assessment by the consulting pharmacist or a physician's documentation that a dose reduction was not recommended. Observations showed Resident 17 experiencing drowsiness and difficulty staying awake, which could be side effects of the medications. Resident 51, admitted with dementia and anxiety disorder, was also on psychotropic medications such as Donepezil, Seroquel, and Ativan. Similar to Resident 17, there was no DRR or GDR assessment conducted, and the physician had not documented that a GDR was clinically contraindicated. The resident exhibited continuous disruptive behaviors, including yelling, which interfered with daily activities and social interactions. The facility's interdisciplinary team managed the residents' psychotropic medication regimens without consulting the pharmacist, leading to a lack of appropriate medication reviews and adjustments.

Removal Plan

• The facility contacted the consulting PH to conduct a drug regimen review for Residents 17 & 51 who were on psychotropic medications for irregularities, appropriateness and make recommendations on GDR's. Additionally, the licensed pharmacist will complete psychotropic drug regimen reviews for the remaining 24 residents on psychotropic medications to assess for irregularities, appropriateness and make recommendations on GDR's.
• All licensed nurses working on 3-11 shift were in-serviced immediately on the need for a licensed pharmacist to review the resident's drug regimen and review duplicate therapy. The Director of Staff Development (DSD) will do another in service for those licensed nurses that were not at the facility. The DSD has a list of those on leave, vacation or who were not able to attend and when they are back on schedule will be in serviced as well.
• This facility will ensure the admission of residents whose needs we can meet according to our Facility Assessment through the utilization of the facility consulting pharmacist to conduct DRR for residents on psychotropic medications for irregularities, appropriate and make recommendations on GDR's. The facility's consulting pharmacist will conduct this monthly for all current and future residents.
• The DON will monitor that the consulting PH has conducted a drug regimen review for residents who are on psychotropic medications for irregularities, appropriateness and make recommendations on GDR's. The DON will report any recommendations made to the resident's physician. The DON will use the audit form to track all GDR recommendations and keep copies of the GDR recommendations in the audit binder with the audit form. The DON will monitor that 100% of the residents on psychotropic medications were reviewed by the consulting pharmacist and will report the findings to the facility's Quality Assurance Performance Improvement quarterly monitoring meetings with a threshold of 100%.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents receiving psychotropic medications were evaluated by a psychiatrist for the appropriateness of their medication regimen. This deficiency affected four residents who were on various psychotropic medications, including Cymbalta, Ativan, Seroquel, Depakote, Mirtazapine, Haloperidol, and Donepezil. These residents had diagnoses such as major depressive disorder and dementia, and the facility did not provide psychiatric evaluations to assess the appropriateness, effectiveness, and need for adjustments in their medication dosages. Resident 2, who had a diagnosis of major depressive disorder, was admitted to the facility and had been taking psychotropic medications since admission without a psychiatric evaluation since February 2023. Similarly, Resident 17, with diagnoses including dementia and bipolar disorder, had not been evaluated by a psychiatrist since November 2021, despite being on multiple psychotropic medications. Resident 19, admitted with dementia and agitation, had never been assessed by a psychiatrist for the need for psychotropic medication since admission. Resident 51, with dementia and psychotic disturbance, had a psychiatric consult ordered but had not been evaluated by a psychiatrist as of the report date. The facility also failed to include a psychiatrist in the Interdisciplinary Team (IDT) meetings to evaluate the residents' behavior and use of psychotropic medication. This oversight led to a lack of proper assessment and planning for the care of residents regarding the need and appropriateness of a gradual dose reduction of psychotropic medications. Additionally, the facility did not adhere to its policies and procedures related to dementia care, antipsychotic medication use, and behavioral assessment, intervention, and monitoring, which contributed to the deficiency.

Removal Plan

• Residents 2, 17, 19, and 51 will be evaluated by a psychiatrist, with evaluations completed. Ongoing monthly psychiatric services will be provided for these residents.
• Evaluations and routine psychiatric services will be completed for residents with psychiatric diagnoses upon admission, thereafter, and as needed by a Psychiatrist.
• The facility will have a monthly Behavioral Intervention Treatment meeting to discuss and review residents on psychotropic medication, with attendance from the Licensed Psychiatrist and the Licensed Pharmacist.
• Residents with a behavioral change in condition will be placed on a 72-hour change of condition monitoring using the facility's Behavior Log.
• All licensed nurses, including IDT members, the DON, the ADON, the ADSS, and the MDS coordinator, were in-serviced on psychiatric diagnosis and the need for a psychologist or psychiatrist consult for residents on psychotropic medication.
• The Director of Staff Development will conduct another in-service for those not present, and will schedule in-services for those on leave or vacation.
• The facility will ensure they can meet the needs of residents with psychiatric or behavioral needs based on the updated Facility Assessment.
• Psychiatric Services have been added to the Facility Assessment, and a psychiatric services company has been obtained to evaluate residents with psychiatric diagnoses.
• A Psychiatrist/Psychiatric Nurse Practitioner will participate in the monthly Behavioral Intervention Treatment meeting for residents receiving psychotropic medications.
• The Psychiatrist/Psychiatric Nurse Practitioner will make routine rounding visits to assess medication effectiveness and dosage needs.
• The facility's DON will monitor residents on psychotropic medications to ensure they receive monthly psychiatric services.
• The Associate Director of Social Services/SSD will report the number of residents and visits to the facility's Quality Assurance Performance Improvement quarterly monitoring meetings with a threshold of 100%.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its infection prevention and control program, specifically regarding the management of suspicious skin rashes among residents. Five residents in the dementia unit exhibited symptoms such as red, inflamed spots with bumps and itching, yet were not placed on isolation to prevent potential spread. The facility also did not conduct proper infection surveillance by completing a line listing of residents with suspicious rashes, which is a critical step in monitoring and controlling potential outbreaks. Additionally, precautionary measures to contain the suspicious rashes were not implemented for the affected residents and others in the secured unit. The facility did not coordinate with the local Department of Public Health for guidance on handling the suspicious rashes, which could have provided essential support and direction in managing the situation. This lack of action increased the risk of spreading the infection to other residents, staff, vendors, and visitors. The report highlights specific cases where residents with dementia, who were dependent on staff for activities of daily living, were affected by the facility's failure to adhere to its policies. For instance, residents with generalized rashes were treated with permethrin cream, but the facility did not follow through with necessary isolation precautions or deep cleaning measures. The facility's policies on scabies identification and infection control were not adequately followed, leading to a situation of Immediate Jeopardy, where the health and safety of residents were at significant risk.

Removal Plan

• The facility conducted body skin assessments on the five residents listed on the IJ document and placed them on contact isolation.
• A line list was created for all 23 CCU residents and staff to monitor for rashes.
• The facility notified the Medical Director and Primary Care Physicians, and dermatology consults were ordered for affected residents.
• The Director of Social Services Department scheduled dermatology appointments for residents whose families agreed to consults.
• The facility notified the CDPH and coordinated with the local regional Public Health Nursing team for guidance.
• All Licensed Nurses and Certified Nursing Assistants were in-serviced on skin issues, infection control, use of PPE, and isolation precautions.
• The Infection Preventionist or designee will monitor and track residents with suspicious rashes, maintain an infection control program, and report findings to the quarterly QAPI monitoring meeting.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prevent the development and progression of a pressure injury for a resident, identified as Resident 50, who was admitted with conditions including dysphagia, atrial fibrillation, and dementia. Initially, the resident was assessed as having no pressure injuries and was at moderate risk for developing them. However, the facility did not adhere to the care plan that required repositioning the resident every two hours to relieve pressure on the left buttock area. Observations showed that the resident was left in the same position for extended periods, contributing to the development of a pressure injury. The facility also failed to update the resident's care plan and Braden scale assessment as the pressure injury progressed from Stage 1 to Stage 4. The Registered Dietician did not assess the resident's nutritional status, which is crucial for wound healing, at any point during the progression of the pressure injury. Additionally, there was no interdisciplinary team meeting conducted to address the resident's nutritional needs or the pressure injury, and no weights were recorded for the resident during this period. Interviews with staff revealed a lack of follow-up and documentation regarding the resident's condition. The Treatment Nurse and Director of Nursing acknowledged that the care plan was not updated as the pressure injury worsened, and the facility did not conduct a change of condition assessment or update the Braden scale. The facility's policy and procedure for pressure injuries were not followed, resulting in the resident experiencing pain and the pressure injury advancing to a severe stage.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to inform the physician of a resident's abnormally low urine output, which was significantly below the reference range. This occurred during a specific shift, and the physician was not notified of the resident's condition, which was a critical oversight given the resident's medical history. The resident, who had congestive heart failure, chronic kidney disease, and was taking diuretics, exhibited signs of dehydration, including sunken eyeballs and dry lips, but these were not communicated to the physician. Additionally, the facility did not initiate a change of condition (COC) when the resident's urine output was observed to be critically low. The resident's care plan included monitoring for signs of dehydration, but there was no documentation that this was done. The Assistant Director of Nursing acknowledged that the resident's low urine output should have prompted documentation and notification to the physician, but this did not occur. The facility also failed to monitor the resident's urine output over a period of several weeks. This lack of monitoring contributed to the resident developing acute kidney injury due to dehydration, which required hospitalization. The Director of Nursing confirmed that the physician should have been notified when the resident's urine output was below a certain threshold, but this protocol was not followed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The Quality Assessment Assurance (QAA) Committee and Quality Assurance Performance Improvement (QAPI) program at the facility failed to identify several critical deficiencies in the care provided to residents. Specifically, the Licensed Pharmacist (LP) did not conduct monthly Drug Regimen Reviews (DRR) of psychotropic medications, nor did they make recommendations for gradual dose reduction (GDR) or dosage adjustments for residents with dementia. Additionally, the facility did not obtain psychiatric services for residents receiving psychotropic medications, which is essential for managing their medications and behaviors effectively. Furthermore, the facility failed to establish and maintain an infection control program for residents with suspicious skin rashes. During interviews, the Medical Director (MD1) and the Director of Nursing (DON) along with the Administrator admitted to being unaware of these systemic failures. The facility's QAPI plan, which aims to proactively improve resident care, was not effectively implemented, as evidenced by these deficiencies. These failures resulted in residents not receiving the appropriate care and services needed to achieve or maintain their highest practicable mental, physical, and psychosocial well-being.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were assessed for the use of pressure pad alarms and that either the residents or their representatives were given the choice to provide informed consent. This deficiency was identified for two residents, one with severe cognitive impairment due to dementia and another with intact cognition but requiring assistance with daily activities. Both residents had pressure pad alarms in place to monitor their movements without having been informed of the risks and benefits, nor had they or their representatives provided informed consent. The facility's policy and procedure on the use of restraints indicated that any device that restricts a resident's freedom of movement and cannot be easily removed by the resident is considered a restraint. Despite this, the facility did not consider alarms as restraints and only obtained a physician's order for their use. The Director of Nursing acknowledged that they were unaware that alarms could be considered restraints and that all residents were equipped with alarms upon admission without proper assessment or consent. This oversight resulted in a violation of the residents' rights to be free from restraints.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide documented evidence of 10 hours of continued education in the field of Infection Prevention and Control (IPC) for key staff members, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD). During an interview, these staff members admitted that they had not completed the required annual continuing education in IPC since their initial training in 2019. This lack of ongoing education was identified during a review of the California Department of Public Health All Facilities Letter (AFL) 20-84, which emphasizes the importance of continuous IPC training to remain updated on new information, trends, and best practices. The facility's policy and procedure document, titled 'Artesia Christian Home Infection Control Program,' was also reviewed and found to be undated. The policy indicated that the facility should establish an infection control program to provide a safe, sanitary, and comfortable environment for residents and staff, aiming to prevent the development and transmission of disease and infection. However, the absence of documented continuing education for the key staff members responsible for infection prevention and control suggests a gap in adherence to these policies and procedures.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its antibiotic stewardship program by not monitoring the use of triple antibiotic ointment for two residents. Resident 1, who was admitted with chronic respiratory failure and generalized muscle weakness, had orders for the application of triple antibiotic ointment on skin tears on the right forearm and left wrist. Similarly, Resident 60, admitted with acute respiratory failure and anemia, had orders for the application of triple antibiotic ointment on a left lower shin abrasion. Despite these orders, the facility did not monitor or address the use of triple antibiotic ointment as part of its antibiotic stewardship program. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility did not include triple antibiotic ointment in its antibiotic stewardship efforts. The facility's policy on antibiotic stewardship indicated that data on antibiotic use should be collected and reviewed quarterly, and that the Infection Control Supervisor should report on antibiotic prescriptions. However, the facility did not follow these protocols for the use of triple antibiotic ointment, leading to a potential for inappropriate antibiotic use for the residents involved.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide documented evidence of COVID-19 vaccination status for all employees, which was identified during an interview and record review with the Assistant Director of Nursing (ADON). The review revealed that the COVID-19 immunization status of 128 facility staff members was unknown. This lack of documentation was in violation of the County of Los Angeles Department of Public Health order, which requires healthcare personnel to either be vaccinated or provide a written declaration of vaccine declination by November 1 of each respiratory virus season. The Director of Nursing (DON) acknowledged the need for updated COVID-19 vaccination status for employees. The facility's policy and procedure, titled Infection Control Plan, aimed to prevent cross infections through immunizations, but the policy was undated and did not appear to be effectively implemented. The failure to document vaccination status had the potential to place staff and residents at risk for negative outcomes related to COVID-19.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for a resident who was noncompliant with his care plan. The resident, who was admitted with chronic respiratory failure, generalized muscle weakness, and a gastrotomy tube, required various levels of assistance for daily activities. Despite having intact cognition, the resident was noted to be particular about his care preferences and often did not comply with safety and feeding plans, as well as his turning schedule. This noncompliance was documented in the resident's Behavior Quarterly Management Follow Up, but no care plan was created to address these behaviors. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility recognized the need for a care plan to guide the resident's care and treatment. However, the ADON confirmed that no such care plan was in place for the resident's noncompliance. The facility's policy on care plans, revised in 2016, mandates the development and implementation of a comprehensive, person-centered care plan with measurable objectives and timetables to meet each resident's needs. The absence of a care plan for the resident's noncompliance was identified as a deficiency, with the potential to delay care and services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise the care plan for a resident who developed a pressure injury on the left buttocks area. Initially, the resident was admitted with conditions including dysphagia, paroxysmal atrial fibrillation, and unspecified dementia. The Minimum Data Set (MDS) indicated the resident had no pressure injuries at the time of assessment. However, the resident was dependent on staff for various activities of daily living. Despite the development of a pressure injury, the care plan was not updated as the injury progressed from Stage 1 to Stage 4. The Treatment Nurse acknowledged that the care plan was not revised to address the progression of the pressure injury. The Director of Nursing stated that the facility's policy requires care plans to be updated with changes in a resident's condition, but this was not done in this case. The facility's policy on comprehensive person-centered care plans emphasizes the need for measurable objectives and timetables to meet residents' needs, which was not adhered to, resulting in a delay in addressing the resident's worsening condition.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate care for a resident with limited range of motion (ROM) and mobility issues, leading to a deficiency in maintaining and improving the resident's physical condition. The resident, who was admitted with dementia and severely impaired cognition, was dependent on staff for activities of daily living. Despite the care plan indicating the need for bilateral lower extremity active assist range of motion (AAROM) exercises, the resident was not receiving ROM exercises on the upper extremities as required by the facility's policy. The Restorative Nurse Assistant (RNA) confirmed that ROM was only being provided for the lower extremities, as it was believed the resident could move the upper extremities independently. Additionally, the facility did not adhere to a physician's order for the application of a left-hand splint, which was intended to prevent further contracture and promote joint extension. Instead, a towel roll was observed in the resident's left hand, contrary to the physician's order for a splint. The Director of Rehabilitation (DOR) assessed the resident and noted stiffness in the left hand, indicating that the resident would benefit from the use of a splint. The DOR also observed that the resident's right hand was at high risk for limitation without intervention, as the resident lacked the cognitive skills to maintain joint mobility independently. The facility's policies on resident mobility and the use of splints were not followed, as the resident did not receive the necessary services to prevent further decline in ROM and maintain mobility. The failure to provide the prescribed ROM exercises and the correct application of a splint placed the resident at risk for further decline in physical condition, including contractures and potential skin breakdown.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary equipment and supplies for managing dialysis emergencies for a resident requiring dialysis care. Resident 6, who was admitted with diagnoses including muscle weakness, end-stage renal disease (ESRD), anemia, and dependence on renal dialysis, did not have an emergency dialysis kit at the bedside. This was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the absence of emergency supplies in the resident's room. Further interviews revealed that the Director of Nursing (DON) confirmed the lack of a dialysis bleed kit at the bedside, indicating that nurses would have to gather supplies in case of an emergency. The facility's policy and procedure for the care of residents with ESRD, revised in 2010, stated that residents should be cared for according to recognized standards, including intervention in medical emergencies such as hemorrhages. However, the facility did not adhere to this policy, as evidenced by the lack of emergency supplies at the resident's bedside.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an injury of unknown origin for a resident who was found with a 1.5 cm by 1.5 cm bluish bump on the left side of her forehead. The resident, who had been admitted with pneumonia and difficulty in walking, had moderately impaired cognition and required assistance during transfers. The injury was discovered by the resident's responsible party and reported to the charge nurse, who noted the bump but did not have an explanation for its origin. The facility's investigation suggested that the injury might have been caused by the resident's agitation and dislike of the stand-up lift used during transfers, but no staff interviews were conducted to confirm this. The Director of Nursing (DON) acknowledged that incidents involving injuries of unknown origin should be reported to the California Department of Public Health (CDPH), but the bump was not reported as it was assumed to be related to the resident's behavior during transfers. The facility's policy requires that all such incidents be reported to the supervisor and further investigated by the Executive Director and DON, with necessary actions taken and reports made to state agencies. The failure to report the injury resulted in a delay of an onsite inspection by CDPH and had the potential for an ongoing unknown injury.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate an injury of unknown origin for a resident, identified as Resident 210, who had a 1.5 cm by 1.5 cm bluish bump on the left side of her forehead. The resident was admitted with diagnoses including pneumonia and difficulty in walking, and her cognition was moderately impaired. The incident was noted in the resident's progress notes, where it was reported that the resident's responsible party noticed the bump and informed the charge nurse. The charge nurse assessed the injury, but there was no report of any fall or injury from the outgoing staff. The facility's investigation suggested that the injury might have been caused by the resident's agitation during the use of a stand-up lift, which she disliked. The Director of Nursing (DON) acknowledged that incidents involving unusual bruises should be investigated and reported. However, the DON assumed the injury was due to the resident's agitation with the stand-up lift and did not interview the staff who worked with the resident on the day of the injury. The facility's policy requires all accidents or incidents to be investigated and reported, but this was not adequately followed in this case, leading to a deficiency in the facility's response to the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident, identified as Resident 210, was free from accidents during transfers using a stand-up lift. Despite Resident 210 exhibiting agitation and combativeness during the use of the lift, the staff continued to use it for transfers to and from the bed. This resulted in Resident 210 sustaining a 1.5 cm by 1.5 cm bluish bump on the left side of her forehead. The resident's admission record indicated diagnoses of pneumonia and difficulty in walking, and her Minimum Data Set (MDS) showed moderately impaired cognition, requiring assistance for transfers. The physician's order noted episodes of agitation, and the Medication Administration Record documented multiple episodes of agitation on a specific day. The facility's investigation concluded that the use of the stand-up lift, which the resident disliked, likely caused the injury. Interviews with staff, including a Certified Nurse Assistant (CNA) and the Director of Nursing (DON), revealed that the resident was uncooperative with the lift, and alternative transfer methods were not explored. The facility's policy on assistive devices emphasized assessing the appropriateness of equipment for the resident's condition, but this was not adequately addressed in Resident 210's case. The care plan for the resident included handling her gently to prevent bruising, but this intervention was insufficient to prevent the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that controlled medications were stored securely, as required by regulations. During an initial tour, it was observed that an emergency kit containing Ativan, a controlled medication, was stored in an unlocked refrigerator at both the North and South Stations. A Licensed Vocational Nurse (LVN) confirmed that the refrigerator was never locked, and the emergency kit with Ativan was kept inside. The Director of Nursing (DON) acknowledged that Ativan is a controlled medication and should have been kept double locked to prevent unauthorized access and potential misuse. The facility's policy and procedure for controlled drugs, revised in December 2015, indicated that controlled drugs should be stored separately from non-controlled medications and under double lock, especially for Schedule II drugs. However, this policy was not followed, leading to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a timely Physical Therapy (PT) and Occupational Therapy (OT) evaluation for a resident, as per the physician's order. The resident, who was admitted with a diagnosis of dementia and had moderate cognitive impairment, was dependent on staff for activities of daily living. A care plan indicated the need for rehab screening or treatment as necessary. A rehab screening note identified moderate to severe limitations in the resident's lower extremities and recommended PT/OT evaluation for contracture and orthotic management. However, despite a physician's order for PT/OT evaluation dated 11/26/2024, the evaluation was delayed. The delay occurred because the Director of Rehab (DOR) missed an email from the Social Services Director (SSD) regarding the insurance authorization received on 12/18/2024. The DOR acknowledged that the PT/OT evaluation should have been completed after receiving the insurance authorization. The facility's policy stated that residents with limited range of motion should receive appropriate services to maintain or improve mobility, but this was not adhered to, resulting in a delay in the resident's evaluation and treatment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the room sizes in a long-term care facility, where six out of eighteen rooms do not meet the required square footage per resident. Specifically, rooms with four beds each measure 305.5 square feet, and rooms with two beds each measure between 151 and 152 square feet, falling short of the regulatory requirement of 80 square feet per resident in multiple occupancy rooms. During an interview, the Maintenance Supervisor stated that the residents in these rooms were not negatively impacted and that there was sufficient space for nursing services. Additionally, the Director of Nursing requested a waiver for the room sizes. Observations during the survey period indicated no issues with residents' access, furniture space, or staff's ability to provide care.

Penalty

Inspection fine: $98,07936 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an accurate assessment for a resident, as evidenced by discrepancies in the Minimum Data Set (MDS) and the Nursing Admission Assessment. The MDS, dated 10/14/2024, inaccurately indicated that the resident did not have any dental issues, while the Nursing Admission Assessment, dated 10/8/2024, noted that the resident was missing two front lower natural teeth. This inconsistency resulted in an inaccurate depiction of the resident's current health status. The resident, who was admitted to the facility with diagnoses including seizures, dementia, age-related osteoporosis, and muscle weakness, was found to have severe cognitive impairment and was dependent on all activities of daily living. During an interview, a registered nurse acknowledged the error in the MDS coding and stated that it should be amended to reflect the resident's dental issues. The Director of Nursing emphasized the importance of accurate assessments to provide a clear representation of the resident's condition.