Edgemoor Hospital

Penalty

Inspection fine: $41,895

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 facility’s failure to protect a cognitively intact resident with quadriplegia from mental abuse and intimidation by a CNA, and failure to recognize, report, and investigate the incident as abuse. The resident, who used a slow-moving electric wheelchair and had a BIMS score of 15/15, asked a CNA to retrieve food from a refrigerator. The CNA responded by demanding that the resident say hello to him if she wanted something, repeating this in an angry manner. When the resident replied that she did not have to say hello if she did not want to, the CNA turned, yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA, and then charged toward her with his chest out and aggressive arm movements. The resident reported feeling scared and defenseless because of her limited mobility and slow wheelchair, and believed the CNA appeared as if he wanted to physically fight her. A second resident witnessed the incident and corroborated the account. Following the incident, the resident called for help and reported to another CNA and the charge nurse that she was scared and did not feel safe with the CNA’s behavior. Staff observations and progress notes documented that the resident appeared in emotional distress at the time of the incident and remained upset and distressed over the following days, including expressing disbelief that the incident had occurred, stating she was not safe with the CNA, and planning to report to the police and Ombudsman. She stayed in bed for several days, refused to get out of bed, avoided social interaction, and declined to keep talking about the incident because she did not want to be retraumatized. Social work and psychotherapy notes documented that she did not feel safe with the CNA, feared he could lose his temper with her or other residents, and that the interaction elicited feelings of unsafety, a sense of being frozen, and led to three consecutive days in bed and avoidance of social interaction. Despite these reports and observations, the charge nurse and CNA who first received the resident’s complaint did not report the incident to the administrator as an allegation of abuse, and the administrator did not interview the resident. The administrator stated she did not consider the incident to be abuse and believed the resident had chosen to file an internal grievance rather than have the incident reported externally. Nursing supervisors did not relay the resident’s statements of fear and emotional distress to the administrator, and one supervisor reported only the CNA’s version of events, omitting the resident’s account. The facility did not complete and submit the SOC 341 abuse report form or report the allegation to the state agency until three days after the incident, and the internal investigation did not begin until that time. During this delay, the CNA, who had a documented history of behavioral concerns noted by the Directors of Staff Development and other staff (including arrogance, resistance to instruction, rudeness, shouting at residents, and unprofessional conduct), continued to be assigned to provide care to residents on two other units, exposing 63 residents to a staff member whose conduct toward the resident had been described by multiple staff as abuse and emotionally distressing. The facility’s own policy defined mental abuse as verbal or nonverbal conduct causing or having the potential to cause humiliation, intimidation, fear, or degradation, including yelling, hovering to intimidate, threatening residents, and depriving a resident of care. Staff interviews, including those of CNAs, the charge nurse, social worker, and Directors of Staff Development, characterized the CNA’s conduct toward the resident as verbal or emotional abuse and intimidation. The facility’s abuse policy required all employees to act as mandated reporters, to immediately report suspected abuse to the administrator and external agencies within specified time frames, to initiate an investigation promptly, and to ensure that staff accused of abuse generally did not have contact with residents during the investigation. These requirements were not followed in this case, leading to a failure to protect the resident from mental abuse and intimidation and a failure to protect other residents from potential abuse. Surveyors determined that this failure to identify and act on the resident’s allegation as abuse resulted in psychosocial harm to the resident, including feeling scared and unsafe, withdrawal from socialization, and ongoing worry, and posed an immediate jeopardy to the safety and well-being of the other residents on the units where the CNA was assigned during the delay in reporting and investigation.

Removal Plan

• Immediately remove any staff member identified as the subject of an allegation involving intimidation, fear, or potential abuse from direct resident care pending investigation.
• Confirm through facility leadership that no residents are currently exposed to staff under investigation.
• Observe the affected resident by nursing staff after the incident and place the resident on monitoring for emotional distress every shift.
• Have the Behavioral Health Program Coordinator attempt to see/assess the affected resident (with follow-up attempts as needed).
• Provide access to facility psychologist and social workers to the affected resident (and all residents) as needed.
• Regardless of investigation type (complaint vs. abuse), if a staff member is an alleged perpetrator, remove the staff member from direct patient care pending abuse investigation results or determination the complaint does not involve abuse.
• Require staff reporting incidents to the Abuse Coordinator to provide thorough and accurate statements based on gathered knowledge, observations, preliminary interviews, and the resident’s psychosocial disposition.
• Report allegations or suspicions of abuse promptly according to required regulatory timelines and submit Form SOC 341.
• Educate staff that they are mandated reporters with the right and obligation to report abuse or suspicion of abuse regardless of others’ opinions.
• Ensure staff are educated and have access to the SOC 341 form and abuse policies/procedures for guidance.
• Provide facility-wide in-service education on staff training for abuse, neglect, and exploitation prevention, with staff on days off/leave/PTO completing education upon return and prior to providing patient care.
• Continue a thorough investigation of the allegations, including resident interviews, staff interviews, witness interviews, employee personnel file review, resident record review, and other items as necessary.
• Submit all investigation results to CDPH within required timelines.
• Have the Administrator/Abuse Coordinator review abuse investigation protocols using the Abuse Investigation Checklist with the Assistant Administrator, DON, ADON, QA nurse, other ADON, and the Behavioral Health Program Coordinator before assuming direct patient care.

Penalty

Inspection fine: $41,895

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 facility’s failure to implement its written abuse policy regarding identification, reporting, investigation, and prevention of abuse. A cognitively intact resident with quadriplegia, admitted after a motor vehicle accident, reported an incident in which a CNA allegedly acted in a verbally aggressive and threatening manner when she requested food from the refrigerator. The resident stated the CNA demanded that she say hello to him before he would help her, repeated this in an angry tone, then yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA. The resident reported that the CNA then charged toward her with his chest out and aggressive arm movements, in a way that appeared as if he wanted to physically fight her. She stated she was scared because her electric wheelchair moved slowly and she was worried she could not get away from him fast enough. Another resident present confirmed witnessing the incident as described. Following the incident, the resident reported the event to another CNA and a charge nurse, telling them she was scared and did not feel safe with the CNA involved. Progress notes documented that the resident appeared to be in emotional distress on the night of the incident and continued to verbalize disbelief and upset about the incident over the next several days. Notes further showed that she stayed in bed, refused to get out of bed, declined to talk to staff about the incident, and avoided social interaction. The resident later told the social worker she did not feel safe with the CNA being around her and expressed concern that the CNA could lose his temper with her or other residents. A psychotherapy note documented that the resident reported feeling unsafe and frozen during the interaction, spending three consecutive days in bed, and avoiding social interaction to prevent retraumatization. Despite these reports and observations, the facility did not identify, report, or investigate the allegation of abuse in a timely and thorough manner as required by its abuse policy. The SOC 341 abuse report was not completed and faxed to the state agency until days after the incident, and the administrator, who served as the abuse coordinator, stated she did not consider the incident to be abuse and did not interview the resident. The administrator reported that she only interviewed the CNA and relied on information from nursing supervisors, who did not relay the resident’s full account or her expressed fear and emotional distress. Staff interviews revealed that the charge nurse and other staff recognized the incident as verbal or emotional abuse and believed it should have been reported immediately, but this did not occur. Additionally, staffing records showed that the CNA continued to be assigned to provide resident care on two subsequent days after the allegation, and there was no documented assessment of risk to other residents during the investigation period, despite the facility’s policy allowing reassignment of accused staff when there is risk to residents. The facility’s abuse policy required immediate reporting of abuse allegations to law enforcement and regulatory agencies within specified time frames, completion of the SOC 341 by the employee who heard about the abuse, and implementation of effective measures to ensure that further potential abuse did not occur while an investigation was in process. The policy also required internal reporting to the administrator and allowed for moving an accused employee to another assignment if there was risk to residents, and it directed that staff be educated to identify behaviors such as increased fearfulness as potential indicators of abuse. In this case, the facility did not follow these procedures: the administrator was not fully informed of the resident’s statements and emotional condition, the resident’s increased fearfulness and withdrawal were not identified or treated as potential signs of abuse under the policy, and the CNA remained in resident care assignments without documented risk assessment. As a result, the facility failed to implement its abuse policy in the areas of timely reporting, thorough investigation, risk assessment for other residents, and recognition of behavioral indicators of possible abuse.

Penalty

Inspection fine: $41,895

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 facility’s failure to recognize, respond to, and report an allegation of verbal and psychological abuse toward a resident, and to protect residents during the investigation. A cognitively intact resident with quadriplegia, as documented by an MDS BIMS score of 15/15 and a diagnosis of quadriplegia due to a motor vehicle accident, reported that a CNA became verbally aggressive when she asked him to retrieve food from the refrigerator. According to the resident, the CNA demanded that she say hello if she wanted something from him, repeated this in an angry manner, then yelled that if she did not say hello she would not get anything from him and would have to call her assigned CNA. The resident stated the CNA then charged toward her with his chest out and aggressive arm movements in a manner that appeared as if he wanted to physically fight her, causing her to feel scared and defenseless due to the slow speed of her electric wheelchair. Another resident witnessed the incident and corroborated the reporting resident’s account. Staff who responded immediately after the incident, including a charge nurse and another CNA, observed the reporting resident to be very shaken, visibly in distress, tense, and shaking, and the resident told them she was scared and did not feel safe with the CNA involved. The resident called for help, asked staff not to leave her alone, and reported that the CNA’s raised voice, intimidating body language, and threatening posture made her feel unsafe. One CNA later stated that the resident reported feeling fatigued, refusing to get up, and not socializing after the incident, and that she considered what happened to be abuse. Despite these observations and statements, the facility’s administrative response did not follow its abuse policy or regulatory requirements. The administrator, who was also the abuse coordinator, stated she only interviewed the CNA involved and did not interview the resident, and that she did not consider the incident to be abuse. The administrator reported that nursing supervisors did not tell her the resident was scared or that this was an abuse allegation, and she believed the resident chose to file an internal grievance instead of requesting that the incident be reported to the state agency. A nursing supervisor acknowledged that she reported only the CNA’s version of events to the administrator, did not relay the resident’s statement, and could not remember what the resident had told her. The facility’s records showed that the CNA continued to provide resident care on subsequent days, and there is no indication in the report that the facility implemented protective measures such as removing or reassigning the CNA while the incident was being investigated, contrary to the facility’s abuse policy and the State Operations Manual requirements to prevent further potential abuse and thoroughly collect evidence.

Penalty

Inspection fine: $41,895

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 facility’s failure to follow its written abuse policy and to timely report and investigate an allegation of abuse involving a cognitively intact resident with quadriplegia. The resident, who used a slow-moving electric wheelchair and had a BIMS score of 15/15, reported that during her first encounter with a CNA, she asked him to get a food item from the refrigerator. The CNA allegedly responded, “Are you gonna say hi to me if you want something from me?” and repeated this in an angry manner. When the resident replied that she did not have to say hi if she did not want to, the CNA allegedly turned around, yelled that if she did not say hi she would not get anything from him and would have to call her assigned CNA, and then charged toward her with his chest out and aggressive arm movements. The resident stated that this behavior appeared as if the CNA wanted to physically fight her, and she felt scared because her wheelchair moved slowly and she was worried she could not get away fast enough. Following the incident, the resident called for help and reported the event to a CNA and the charge nurse, stating she was scared, did not feel safe, and did not want to be left alone with the CNA involved. A second resident who witnessed the incident confirmed the described events. The charge nurse observed the resident to be very shaken, visibly in distress, and reporting fear. Another CNA reported that she heard the resident screaming her name, found the resident tense and shaking, and was told by the resident that the CNA’s raised voice and body language were intimidating and threatening. This CNA also reported that the resident later felt fatigued, refused to get up, and did not socialize after the incident. Both the charge nurse and the CNA later characterized what happened as abuse. Despite these reports and observations, the incident was not treated and reported as an abuse allegation in accordance with the facility’s abuse policy and regulatory requirements. The policy required that all employees, as mandated reporters, immediately report evidence or suspicion of abuse to the administrator or supervisory nurse, report all abuse to law enforcement by phone immediately, and fax the SOC 341 to the Ombudsman and CDPH within two hours of observation or report. Instead, the charge nurse and CNA did not report the resident’s allegation as abuse to the administrator at the time, and the facility did not initiate a thorough investigation when the incident was first reported. A nurse supervisor later reported the incident to the administrator based only on the CNA’s account and did not include the resident’s statement, and she could not recall what the resident had told her. As a result, the SOC 341 reporting the incident of psychological/mental abuse and verbal aggression was not faxed to CDPH until three days after the alleged incident, contrary to the facility’s policy and required time frames.

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

Safe food handling practices were not maintained during tray line service for pureed diets for 16 of 157 residents. During lunch puree diet preparation, the Chief of Nutritional Services stated there were 16 residents receiving pureed diets and that 18 servings were prepared for extra-large portions. During lunch tray line, the pureed diet consisted of layered pureed crust topped with pureed sausage and pepperoni, red sauce, and white cheese sauce. Food Service Worker 2 was observed dipping a blue-handled scoop into a red bucket containing water and disinfectant solution located below the tray line table, then placing the wet scoop into the white cheese sauce and continuing service for the pureed diets. During interview, the CNS and RD were informed of the observation. The CNS stated the scoop should have been allowed to dry before being placed in the cheese sauce to avoid contamination. The CNS then confirmed that Food Service Worker 2 admitted dipping the scoop in the red bucket after rinsing it in water because it was dirty from food by the handle, and that she did not allow it to dry first. The CNS stated that placing the scoop in the white cheese sauce after the red bucket had the potential for the sauce to be contaminated. The DON stated she expected all food service workers to perform safe food handling practices so residents did not become ill. The facility policy stated employees shall avoid touching food contact surfaces of dishes and serving utensils and use suitable utensils such as scoops to handle food during preparation and service.

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 properly store and label a resident’s pain medication. Resident 54 had a physician order for diclofenac gel to be applied topically to both knees every shift routinely for pain. During a concurrent observation and interview, surveyors found an unlabeled, undated, and unpackaged topical gel medication on top of the resident’s bedside drawer while the resident was in bed. The resident stated the medication was his topical pain medication for his shoulder and knee joints and said he was supposed to administer it after showering, but had been in a hurry because family was there to pick him up. He also stated he had just returned from an out-on-pass with a relative and would administer the medication himself. During interviews, LN 8 stated she did not leave the medication at the resident’s bedside. LN 9 stated she was supposed to administer the medication after the resident’s shower that morning and acknowledged she should not have left it at the bedside; she identified the medication as the resident’s diclofenac topical gel. LN 10, the DON, and the ADON all stated medications should not be left at the bedside for safety because another resident could take them. The facility policy titled Self-Administered Medications, dated 5/22/2024, stated no medications are to be stored at a resident’s bedside without a physician’s order.

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 food brought in from outside and stored in designated resident refrigerators was discarded in a timely manner for two resident refrigerators. In one refrigerator, a white plastic grocery bag labeled with Resident 114's name contained store-bought sour cream, shredded cheese, and an opened but sealed bag of flour tortillas; the tortillas had a discard date of 12/3/25 and were still present during the survey observation. Licensed Nurse 1 reviewed the refrigerator log and stated the night shift was responsible for inspecting and discarding labeled foods, and confirmed the tortillas should have been thrown away because they were old. In another resident refrigerator, a half-consumed cup of Vietnamese coffee labeled with Resident 24's name was found inside a sealed plastic bag with a discard date of 12/2/25. Licensed Nurse 2 reviewed the refrigerator log and stated the food had been inspected by night staff, but the coffee should have been discarded on the labeled date. The DON stated that all resident food brought in from outside needed to be discarded after 48 hours, and the CNS stated resident refrigerators should be locked when not in use and that outside food should always be discarded after 48 hours.

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 possible cross contamination when Resident 159’s urinary collection bag was observed in contact with the floor. During an initial tour on 12/1/2025, Resident 159 was asleep in bed with a urinary collection bag clipped to the left side of the bed and covered by a blue/black dignity bag; the dignity bag was touching the floor. During the observation, LN 3 stated the bag should not be on the floor because the floor was dirty and bacteria could travel up to the catheter, causing an infection. Resident 159’s record showed admission with a urinary catheter due to malignant neoplasm of the bladder. On 12/2/2025, Resident 159 was again observed in bed with the urine collection bag and dignity bag on the left side of the bed, and the dignity bag was leaning sideways and in contact with the floor. CNA 1 stated the urinary collection bag should not be on the floor because the floor was dirty and could cause an infection. The ICP and DON also stated urinary collection bags and tubing should never be in contact with the floor, and the facility policy for indwelling catheter care stated bags should be kept below the level of the bladder, but not on the floor.

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 adequate supervision for a resident with dysphagia and a history of choking during meals. The resident, who had intact cognition and was able to feed himself, was observed eating alone without the required 1:1 supervision as outlined in his care plan. Despite the resident's known tendency to eat quickly and cough, staff only performed spot checks rather than continuous supervision. This lack of supervision was confirmed by multiple staff members, including a Restorative Nursing Assistant and a Licensed Nurse, who were unaware of the care plan's requirement for 1:1 supervision. The resident had experienced previous choking incidents, including one where the Heimlich maneuver was necessary. The Speech Language Pathologist emphasized the need for 1:1 supervision due to the resident's limited upper extremity movements and non-compliance with diet orders. The Director of Nursing acknowledged the expectation for 1:1 supervision as per the care plan, highlighting a disconnect between the care plan and its implementation. The facility's policy on assisting residents with eating was not followed, as trays were placed in front of the resident without ensuring the availability of help, and there was no consistent monitoring of the resident's swallowing during meals.

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 identify and report an injury of unknown origin as possible abuse for a resident, which is a violation of their abuse policy and procedure. The resident, who had Alzheimer's disease, vascular dementia with behavioral disturbance, and hearing loss, was found with a dark purple discoloration around her right eye and additional bruises on her left forearm. The staff, including a CNA and a Licensed Nurse, were unsure of how the injuries occurred, with suggestions of a possible fall, but no definitive cause was determined. The resident's cognitive impairments made it difficult for her to communicate how the injuries happened. The Director of Staff Development acknowledged that the bruise should have been considered possible abuse due to its unknown origin and emphasized the importance of reporting such injuries to ensure resident safety. Despite this, the facility did not report the injury to the California Department of Public Health, as required by their policy and state law. The Director of Nursing and the Administrator were involved in the incident's review, with the Administrator noting that the hospital had reported the bruise to the state agency, but the facility itself did not. The facility's policy on injuries of unknown origin and abuse reporting mandates that all employees comply with reporting requirements. However, in this case, the facility did not adhere to these policies, as the injury was not reported, and the potential for abuse was not adequately investigated. This oversight placed the resident and potentially other residents at risk for further abuse and delayed the investigation process.

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 call light was within reach for a resident diagnosed with hemiplegia and hemiparesis, conditions that impair movement and strength on one side of the body. This deficiency was identified during an observation and interview with the resident, who reported inconsistent assistance from staff and an inability to reach the call light to request help. The resident was observed sitting in a specialized wheelchair, unable to reach the call light, and expressed a need for assistance with basic needs such as getting a drink and personal hygiene. Further investigation revealed that the resident's care plan required the call light to be within reach and for staff to respond promptly to requests for assistance. Interviews with facility staff, including a CNA and the ADON, confirmed that the call light was not within the resident's reach, which contradicted the facility's policy. The resident's Minimum Data Set indicated a need for staff assistance with transfers, bathroom use, and personal hygiene, highlighting the importance of accessible call lights for timely assistance.

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 kitchen staff competently performed and carried out the functions of the Food and Nutrition Services department. During an initial kitchen tour, a food services worker was unable to correctly operate the dishwashing machine. The worker attempted to demonstrate how the kitchen staff ensures accurate temperatures but was unable to do so as the display was not a touch screen. The Chief of Nutrition Services later explained that the dish machine sanitizer is tested using a test strip, which changes color to indicate the correct temperature. However, the facility's job description for food services workers requires them to operate and maintain kitchen equipment safely and efficiently, which was not demonstrated in this instance. Additionally, another food services worker was unable to properly demonstrate how to calibrate a food thermometer. The worker used a personal thermometer, which had a dead battery, instead of the facility-provided thermometer. The Chief of Nutrition Services stated that the kitchen staff is expected to use the facility-provided thermometers, which were approved by management, and acknowledged the importance of staff being trained on their use. The facility's job description for food services workers includes knowledge of safety practices related to food preparation and the use of kitchen equipment, which was not adhered to in this case.

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 food safety and sanitation practices in the kitchen, as observed during a survey. The ice machine was found to have black debris inside the ice-making parts, and the maintenance staff did not follow the manufacturer's cleaning instructions, which require thorough cleaning and sanitizing of all internal water contact areas. The Chief of Nutrition Services (CNS) and the Plant Operations Director (POD) acknowledged the issue, noting that the maintenance department was responsible for cleaning the ice machine quarterly but did not remove certain parts during the cleaning process. Additionally, the facility did not ensure proper food storage and handling. Two large onions in the refrigerator were found to have mold, and the CNS admitted that the staff should have removed them as they were no longer fit for consumption. Furthermore, three floor sinks had pipes without the required air gap, which could lead to contamination. The CNS acknowledged the improper setup of the pipes, which should not extend into the floor drains without an appropriate air gap, as per the facility's policy and the 2022 Federal FDA Food Code. The facility also failed to maintain clean and safe food preparation surfaces. Two cutting boards with deep cuts and food stains were stored in the clean area, and the CNS stated that the cutting boards should be replaced. The Nutrition Services Supervisor (NSS) confirmed that the cutting boards were checked daily for wear but acknowledged that the boards in question were not safe for use. These deficiencies in food safety and sanitation practices exposed residents to potential foodborne illnesses due to contaminated food and unsanitary conditions.

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 the Centers for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBPs) for 26 out of 29 residents with indwelling medical devices. Observations revealed that these residents were not placed on EBP, despite having medical devices such as feeding tubes and urinary catheters. Interviews with staff, including Supervisor Nurse 41 and Certified Nursing Assistant 22, indicated a misunderstanding of the EBP criteria, with some staff believing it was only applicable to residents with COVID-19. The Infection Preventionist (IP) and other staff members acknowledged that their interpretation of the CDC guidelines might be incorrect, and the facility's unique characteristics were considered in their assessment tool. Additionally, a Licensed Nurse (LN 1) failed to use appropriate Personal Protective Equipment (PPE) when administering tube feeding to Resident 88, who was on Enhanced Standard Precautions. During an observation, LN 1 was seen wearing gloves but not a gown while connecting a syringe to the resident's feeding tube. LN 1 admitted to not following the PPE requirements, which were clearly indicated on a sign outside the resident's room. The Charge Nurse and Assistant Director of Nursing (ADON) confirmed that LN 1 should have worn both gloves and a gown, as per the facility's policy and the posted instructions. The facility's policy on Enhanced Standard Precautions/Enhanced Barrier Precautions was reviewed, and it was found that the policy required the use of gowns and gloves for high-risk residents, particularly those with wounds or tubes. The policy also outlined the communication process for these precautions, including placing a sign outside the resident's door. Despite these guidelines, the facility's staff did not consistently adhere to the policy, leading to potential risks of infection spread within the facility.

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 kitchen equipment in safe operating condition, as observed during a survey. The dishwashing machine was found to have temperatures below the required sanitation level. During an observation and interview, the food services worker/dishwasher (DSW) explained the process of washing and sanitizing dishes, which involves several cycles including power scraper, power wash, power rinse tank, and final rinse. However, the gauges on the dish machine indicated that the wash temperature was not reaching the appropriate level, with the power wash cycle only reaching 140 degrees Fahrenheit, below the facility's policy requirement of 150 degrees Fahrenheit. The Clinical Nutrition Specialist (CNS) acknowledged the issue, stating that the dish machine needed repair to ensure proper operation. Additionally, the survey identified issues with a reach-in refrigerator and freezer, both of which had condensation build-up. The reach-in freezer had frozen liquid on the bottom shelf and frozen condensation on the racks, while the reach-in refrigerator had ice condensation on the bottom shelf and inside the door. According to the 2022 Federal FDA Food Code, such condensation can lead to food adulteration and contamination with pathogenic organisms. The facility's policy on essential equipment emphasized the importance of maintaining equipment to prevent risks to resident health and safety.

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 honor the preferences and choices of three residents, leading to a deficiency in promoting resident self-determination. Resident 119, who was admitted with diagnoses including weakness and leg amputation, expressed dissatisfaction with the facility meals and desired to store and reheat food purchased from outside. Despite having intact cognition, Resident 119 was denied access to the unit refrigerator and microwave, which were reserved for staff use only. The facility's policy restricted residents from storing frozen food and limited the storage of other foods to 48 hours, although staff were not aware of the reasons for these restrictions. Similarly, Resident 131, with a diagnosis of spine injury, preferred food from outside sources and faced similar restrictions. He was informed that only pre-packaged, sealed food could be stored in the unit refrigerator, and there was no microwave available for resident use. Despite his intact cognition, Resident 131 was not allowed to reheat food in the facility's kitchen, contrary to his experiences in other nursing homes. The facility's guidelines and policies were cited as reasons for these restrictions, although the Assistant Director of Nursing acknowledged that resident preferences should be accommodated. Resident 126, admitted with a diagnosis of weakness, faced issues with the facility's purchasing process. Despite having money and being able to express her needs, she did not receive the specific brands of items she requested, such as shampoo and pistachio nuts. The facility's checklist for purchases did not specify brands, and staff were instructed to inform residents that their requests were considered wants, not needs. The Assistant Director of Nursing mentioned that they would ask the resident's family to obtain the preferred items, indicating a lack of direct support from the facility in fulfilling resident preferences.

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 distribute mail to residents on Saturdays, affecting five Resident Council attendees. During a Resident Council interview, all attendees reported that mail was not delivered to them on Saturdays, and they expressed a desire to receive their mail on that day. The Social Services Aide (SSA) confirmed that mail distribution was only conducted from Monday to Friday, as social services staff did not work on weekends. The Assistant Director of Nursing (ADON) also acknowledged that social services staff were unavailable on Saturdays and stated that residents would receive their mail on Monday if expected over the weekend. The facility's policy on resident mail, dated June 13, 2023, indicated that weekend mail delivery was generally unavailable, and residents could pick up their mail if desired, despite the absence of social services staff to assist them.

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 the Minimum Data Set (MDS) was accurately coded for a resident diagnosed with long-standing schizophrenia. Upon admission, the resident's diagnosis of schizophrenia was not reflected on the initial MDS assessment and three consecutive MDS assessments, despite the resident having a physician's order for olanzapine, an antipsychotic medication, specifically for schizophrenia. The resident's History and Physical (H&P) also indicated a diagnosis of schizophrenia, yet this was not marked as an active diagnosis on the MDS assessments. Interviews with the MDS Coordinators revealed that the MDS was completed based on the physician's diagnosis list, and if schizophrenia was not listed, it would not be included in the MDS. The MDS Coordinator did not recall questioning the physician about the omission of schizophrenia, despite the medication order and the resident's psychiatric history. The Medical Director acknowledged that the initial MDS should have indicated schizophrenia as an active diagnosis, and the Assistant Director of Nursing recognized the importance of accurate MDS coding to drive the resident's care plan.

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 activities care plan for a resident who expressed interest in activities related to his past profession as a furrier and tailor. Despite the resident's expressed desire to engage in sewing or design activities, the care plan only included general activities such as games and outdoor strolls, without addressing his specific interests. The Director of Activities acknowledged the oversight, confirming that the resident's care plan did not reflect his preferences, which is contrary to the facility's policy requiring care plans to be specific and reflective of residents' goals and preferences. Additionally, the facility did not implement a call light care plan for another resident who required assistance due to hemiplegia and hemiparesis. The resident reported inconsistent help and difficulty reaching the call light, which was observed to be placed out of reach. A CNA confirmed the call light was inaccessible, and the Assistant Director of Nursing acknowledged that the care plan, which required the call light to be within reach, was not followed. This failure to implement the care plan as documented could lead to unmet needs for the resident, as the facility's policy mandates care plans to address individual needs with specific interventions.

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 an activity program that met the preferences of a resident, identified as Resident 31, who was reviewed for activities. Resident 31, a former furrier and tailor, expressed a desire to engage in activities related to his past profession, such as sewing and design. However, the facility did not offer any activities that aligned with these interests. During an observation and interview, Resident 31 mentioned missing these activities and expressed a wish to continue them, but stated that he was unable to do so in the facility. Interviews with the Director of Activities and the Assistant Director of Activities revealed that although Resident 31 had mentioned his career, the facility had not provided any related activities. The Therapeutic Recreation Assessment for Resident 31 included recommendations for games, outdoor strolls, and social interactions but did not reference any activities related to sewing or design. The facility's policy on Therapeutic Recreation Services emphasized the importance of providing a comprehensive assessment and ongoing program of activities to promote residents' well-being, yet this was not reflected in the activities offered to Resident 31.

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 Resident 18 received adequate nutrition through tube feeding, resulting in a 6.6% weight loss over one month. Observations revealed that the resident's tube feeding equipment was not properly set up, with no formula or water hanging from the kangaroo pump on multiple occasions. The resident, who was non-verbal and had several medical conditions including dysphagia, kidney failure, and malnutrition, was observed in a state that suggested inadequate nutritional support. The facility's records indicated that Resident 18 had a significant weight loss of 19.3% over 12 months, yet the facility continued to use ideal body weight (IBW) for nutritional calculations instead of actual body weight, which is the current standard of practice. Interviews with the Registered Dietitian (RD) and Medical Director (MD) revealed a lack of awareness regarding the correct standard for weight calculations and the resident's recent weight loss. The RD admitted that the total calories from the tube feed order did not meet the assessed caloric needs of Resident 18. The facility's policies and procedures were not effectively implemented, as evidenced by the RD's lack of recent physical assessment of the resident and the failure to adjust nutritional support based on current lab results and weight changes. The Assistant Director of Nursing (ADON) and Chief of Nutrition Services (CNS) also demonstrated a lack of understanding of the appropriate standards for weight assessment and nutritional care, contributing to the deficiency in providing adequate nutrition to Resident 18.

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 Resident 18 received the prescribed tube feeding volume according to the facility's policy. Observations revealed that the resident, who was non-verbal and had a gastric tube for feeding, was not receiving the required Jevity 1.5 formula as per the physician's diet orders. The kangaroo pump machine used for administering the tube feeding was found to be turned off and without formula or water hanging on it during multiple observations. Interviews with licensed nurses indicated a lack of proper documentation and understanding of the kangaroo pump machine's functionality. Nurses relied on the machine's limited data storage for tracking formula intake, which only stored data for up to 72 hours. There was no documentation of daily intake amounts, and some nurses were not trained on how to check the machine for previous formula volumes. This lack of documentation and training contributed to the failure to administer the prescribed tube feeding volume. The facility's policies required licensed staff to document enteral feeding volumes in the Intake and Output Record, but this was not being done. The Assistant Director of Nursing acknowledged the importance of tracking tube feeding formula volume and the limitations of the kangaroo pump machine. Despite the facility's policy and the resident's nutritional needs, the prescribed feeding regimen was not followed, potentially leading to adverse health outcomes for the resident.

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 medication was administered as ordered by the physician for one of the residents reviewed during a medication administration observation. Specifically, during a medication pass observation, a licensed nurse prepared and administered five medications for a resident diagnosed with iron deficiency anemia but failed to include ferrous sulfate, which was ordered daily for the resident's condition. The licensed nurse acknowledged the omission during a concurrent interview and record review, recognizing that missing a medication dose could negatively affect the resident. The facility's policy on medication safety emphasizes the importance of preparing, administering, and documenting medications in compliance with physician orders and pharmacy recommendations.