Alta Mesa Health And Rehabilitation

Based on facility documents, staff interviews and facility policy, the facility failed to ensure the Daily Staff Postings for nursing staff was accurate and completed for the number of staff hours scheduled and hours worked.

Findings Include:

A review of the 2024 Alta Mesa Health and Rehabilitation Facility Assessment addressed the staffing plan, charts, and assignments for the facility. According to the assessment, the facility utilized information collected in the resident profile to identify the care and services needed for the residents. The assessment included a sample staffing chart which calculated that the services of 1-2 registered nurses were appropriate for Long-Term Care and Short-Term Care (skilled) residents. The assessment further stated that staffing is ultimately is determined by the census, resident acuity and needs.

A review of the PBJ Staffing Data Report for Fiscal Year Quarter 3, 2024 (April 1-June 30), identified the facility as having an excessively low weekend staffing finding.

Review of the Daily Staff Posting dated July 6, 2024 revealed no evidence of the registered nurse assigned to the unit as a charge nurse. Further review of the posting revealed 3 Licensed Practical Nurses (LPN) worked the 6 am to 6 pm shift, with scheduled hours worked, and actual hours worked of 33.41 hours, after recalculation with the coordinator, it was determined the value was approximately 37.6 hours actually worked.

The Daily Staff Postings dated from October 21, 2024 thru November 6, 2024 posting failed to include the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. The hours reflected in the Time Tracking: Daily Punch Details, did not correspond to the postings

The Daily Staff Postings dated November 13, 2024 during the 6 am to 6 pm shift revealed 4 RN's were scheduled to work 36 hours, with an actual worked hour of 35.95 hours. Punch details are listed below:
-RN #1 total of 7.62 hours
-RN #2 total of 12.18 hours
-RN #3 total of 11.57 hours
Cumulative Hours of 31.37.
On this date there was a total of 3 RN's with an actual worked hour of approximately 31.37 ours. There is a 4.58-hour difference between the posting and punch details.

According to the Center for Medicare Services (CMS website) as of November 20, 2024, the facility has a below average (two star) rating for staffing. The Registered Nurse hours per resident per day on the week average for the weekend was recorded at 23 minutes. The national average was 28 minutes. The Arizona average was 30 minutes.

Observed with the staffing coordinator the miscalculations transcribed on the Daily Staff Posting dated July 6, 2024.

Observed with the coordinator the Daily Staff Postings dated from October 21, 2024 - November 6, 2024, where the actual hours worked column were left blank.

On November 18, 2024 during the initial pool screening, multiple alert and oriented residents complained of long wait times for care and voiced the following concerns:
-One resident stated being at for facility for a total of 4 months, and feels short staffing is definitely a problem. The resident feels the facility should have a better backup plan in place because things are not getting done like they are supposed to on the weekends. Resident stated they were so short staffed this weekend, his vital signs were only taken once, instead of the usual three times a day.
-One resident stated it took 3 hours to get to the commode and is frustrated because they are always short staffed.
-One resident stated that he prefers to go to the bathroom to have a bowel movement, but because of his decreased mobility, he has to consistently defecate in his adult brief.
-One resident feels they are extremely slow in answering call bells.
-One resident's spouse stated frustration with the facility staffing and stated "You cannot expect one CNA to take care of everyone! One CNA for 28 residents is ridiculous!"
- One resident admits to having to call the front desk to get assistance because the staff takes to long to answer call lights.

An interview was conducted with CNA (Staff #39) on November 19, 2024 at 9:23 a.m. The CNA stated that she is usually takes care of about 15-17 residents depending on needs. She states some responsibilities of her day includes grooming, and dressing, giving showers, assisting residents with whatever is needed. The CNA feels she has enough time to complete her required assignments during her shift. In regards to the weekend shift, she stated she doesn't work on the weekend. She also feels 4 CNA's and a shower aid optimal staffing for the CNA's.

A joint interview with the staffing coordinator (Staff #31) and the administrator (Staff # 83) was conducted on November 20, 2024 at approximately 1 pm, to address the actual hours worked discrepancies, and to discuss concerns about staffing.

The staffing coordinator stated that staffing is done according to acuity and census. She included that resident's that require 2-person care are also considered in staffing decisions. The staffing coordinator stated the average census for the last 3 months is between 55-63. As far as direct care resident staff, there are typically 4 CNA's, and 3 licensed nurses for the building.

The administrator voiced his appreciation for the hospitality aides that assist the residents and provides support to the staff. The administrator and coordinator admit sometimes the staffing coordinator has a tendency towards not catching mathematical errors and any mathematical errors are unintentionally transferred to the Daily Staff Posting.

The administrator explained that in case of direct care staff call outs they always have someone to fill in. The administrator admitted to feeling fortunate that registry staff were not utilized at the facility. He states that some of the staff live within a 10-minute vicinity to aid if needed.

The administrator stated they do sometimes receive complaints about staffing and long call light wait times. He explained they conduct call light audits and they take an in-depth look into each complaint. After the investigation concludes, often times the actual wait times were not as long as initially perceived.

The administrator stated they are definitely not understaffed, and to ensure that, they always have recruitment efforts going on. In regards to the Center for Medicare Services (CMS) 2-star staffing rating, the administrator believes the rating is actually higher, but they unfortunately did not submit some employee data correctly.

A follow up interview was conducted with the staffing coordinator on November 20, 2024 at approximately 14:00. The coordinator acknowledged on the day of July 6, 2024 the facility census was 68. During the interview, the surveyor and coordinator used daily punch details, staff sign in-sheet, and the daily staff posting for July 6, 2024 to verify discrepancies in the posting. The coordinator identified missing time punches as a barrier in tabulating the final actual hours worked column correctly She states staff are always encouraged to properly clock in and out.

The facility policy titled ADL's calls for the facility to provide residents with the appropriate treatment and services to attain or maintain the highest level of resident well-being.

The facility policy titled Sufficient Staffing ensures the facility is to have sufficient nursing staff with the appropriate competencies and skillsets, in accordance with the facility assessment.

Based on resident and staff interviews, clinical record review, policy review and observations, the facility failed to ensure that one of one sampled resident (#510) was administered oxygen as ordered.

Findings include:

Resident #510 was admitted on November 15, 2024 with diagnoses that included influenza due to novel influenza A virus with other respiratory manifestations.

A physician ' s order dated November 16, 2024 revealed an active order for oxygen at 2 liters per minute (LPM) via nasal cannula (NC) continuous, may titrate to 5 LPM to keep oxygen saturation above 90%.

Review of the November 2024 Medication Administration Record (MAR) revealed evidence that oxygen had been administered via NC at 2LPM between November 16, 2024 to November 20, 2024.

A care plan dated November 18, 2024 revealed a focus for oxygen therapy related to ineffective gas exchange, and the interventions included giving medications as ordered by the physician, and to monitor/document side effects and effectiveness.

An admission Minimum Data Set (MDS) assessment dated November 20, 2024, revealed a Brief Mental Interview Assessment (BIMS) score of 15 which indicated no cognitive impairment. The MDS was in progress and there was no evidence of assessments in other areas.

During an initial observation conducted on November 18, 2024 at 8:53 a.m. of resident #510 who was sitting up in bed and there was no evidence that the resident was being administered oxygen; nor was there evidence of oxygen related supplies in her room (ex. Nasal cannula, tubing, or oxygen tank and/or concentrator).

A second observation of the resident was conducted on November 20, 2024 at 10:50 a.m. and the resident was observed to be sitting up in her bed and there was no evidence that she was being administered oxygen nor had oxygen related supplies in her room.

A final observation of the resident was conducted on November 20, 2024 at 1:19 p.m. and there was no evidence that the resident was receiving oxygen.

An interview was conducted on November 20, 2024 at 10:50 a.m. with Resident #510, who stated she had not been administered oxygen since admission

An interview was conducted on November 20, 2024 at 11:06 a.m. with a Certified Nursing Assistant (CNA/Staff #61). Staff #61 revealed that the facility process for administering oxygen would be to ensure that the resident is being administered the right dosage and ensure that the system is functioning properly. The CNA stated she was familiar with the patient and did not recall ever seeing her on oxygen. The CNA then entered the room and confirmed the resident was not currently being administered oxygen.

An interview was conducted on November 20, 2024 at 11:55 a.m. with a Licensed Practical Nurse (LPN/Staff #113), who stated that the process for administering oxygen would be to obtain a physician ' s order and administer as written, as this is the facilities expectation.The LPN stated the risks of not administering oxygen as ordered could result in low oxygen saturation which could lead to harm. Staff #113 reviewed the physician's order and verified an order to administer oxygen at 2LPM via NC continuously and to change the oxygen tubing weekly. She then stated that it was her first time working with Resident #510 and she was unaware if she had been administered oxygen but had not seen the resident on oxygen that morning.

An interview was conducted on November 20, 2024 at 1:06 p.m. with the Assistant Director of Nursing (ADON/ Staff #76), who stated that oxygen is administered according to physician ' s orders. The ADON reviewed Resident #510 ' s clinical record and verified that the resident had an order for continuous oxygen, and verified that it was being charted in the November 2024 MAR that the resident had been receiving oxygen. The ADON stated that his expectations would be to administer oxygen as ordered. The ADON identified that the risks of not administering oxygen as ordered could lead to respiratory issues such as hypoxia.

Review of facility policy titled, Oxygen Administration, revealed that oxygen therapy is ordered by physician and the resident's clinical record will include: that oxygen is to be administered, and oxygen concentrators will be maintained in room when oxygen ordered.

Review of another facility policy titled, Physician Orders, revealed that it is policy of this facility that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs. Further review revealed, it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care.

Based on clinical record review, interviews, policy and procedure, and observation of current practice, the facility failed to ensure on resident (#215) received treatment and care in accordance with professional standards.

Findings included:

Resident #215 was initially admitted to the facility on December 14, 2022 and readmitted on July 16, 2013 with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, acute on chronic combined systolic and diastolic heart failure.

A hospital discharge summary dated July 16, 2023 revealed resident was discharged with a diagnosis of osteomyelitis. Instructions stated if resident is on vancomycin, then Vancomycin trough on day #3, then weekly after is checked, keep the level between 15 and 20, and Skilled Nursing Facility Pharmacist to dose per their protocol.

Review of the physician order revealed an order for vancomycin hydrochloride intravenous solution 500 milligram (mg)/100 milliliter (ml) to use 1.25 mg intravenously one time a day for osteomyelitis for 8 weeks initiated on July 16, 2023. Review of a progress note dated July 16, 2023 regarding the above order that the dose failed a general dose range check based on drug inputs and/or information provided and that the drug's dose should be adjusted based on renal function.

The physician order also revealed an order for vancomycin trough one time only for 1 day to draw 30 minutes prior to the 4th dose, initiated on July 20, 2023.

The medication was transcribed in the MAR (Medication Administration Record) and revealed vancomycin hydrochloride was administered from July 17, 2023 to July 23, 2023. In addition, the vancomycin trough was marked as complete on July 21, 2023 at 8:27 AM.

A lab results reported on July 21, 2023 at 3:02 PM revealed a vancomycin serum trough level of 49.6 microgram (?g)/mL, which was flagged as a critical result. The report stated the result was called to the facility on July 21, 2023 at 6:27 PM.

Review of records revealed no documentation that the pharmacy or the physician was notified upon receipt of the critical lab result.

A progress note dated July 24, 2023 at 6:20 AM stated the patient was found unresponsive and cardiopulmonary resuscitation was initiated. The noted also stated the resident had a time of death at 6:58 AM in the hospital.

An interview was conducted on September 12, 2023 at 12:31 PM with an LPN (Licensed Practical Nurse/Staff #60 who stated vancomycin trough was monitored for residents who are on vancomycin because the medication was a "harsh chemical" for the body. Staff #60 stated that trough is regulated every 4th dose to maintain certain level, drawn before the 4th dose and the dose adjusted if necessary. Staff #60 stated that if trough is elevated then the Assistant Directors of Nursing (ADON) are notified, who then notifies the Director of Nursing, who will reach out to the provider and wait for instructions to either change the dose or hold the medication. The LPN (staff #60) stated that the provider is notified because they are "medicine" and their purview. Further, he stated that he would reach out to the ADON and inform them of the labs and help navigate and would hold the next dose until he receives clarification. When asked what the risks were for giving the next dose when trough levels were high, staff #60 stated he was unsure but his next action was to notify the physician.

An interview was conducted on September 12, 2023 at 12:42 PM with an ADON (staff #102) who stated that trough levels were monitored for residents being treated with vancomycin. He said that depending on the infectious disease provider what is monitored such as kidney functions and other labs. The ADON stated that pharmacy monitored and adjusted the dose for vancomycin for therapeutic levels. Further, before the resident received the next dose, pharmacy would give recommendation on the dosage. The ADON stated that if there were reports of elevated trough level then the next action would be to notify pharmacy to fully integrate and get the next dosage. He stated that the medication was not skipped until guidance from pharmacy was received. Staff #102 said if the trough level was critically high or low, the provider was notified immediately and get orders. Further, he stated that the medication is not held but actions were based on the provider's instructions. He stated, the notification was noted on the resident's record as either lab, change of condition, change to order, and recommendation from pharmacy. Per the ADON, the normal level for trough was on the high end of 15 and if it was elevated it was up to pharmacy's discretion, per provider order. He stated that the risk of not notifying the provider of elevated trough was that the resident can experience side effects of red man's syndrome. In addition, his expectation was to notify the provider for high lab results because it could affect kidneys-vancomycin toxicity.

An interview conducted on September 12, 2023 at 1:05 PM with the DON (Director of Nursing/Staff #12) who stated that when a resident was receiving vancomycin, trough, weekly labs, and toxicity levels were monitored and managed by pharmacy. The DON stated that staff drew the labs and pharmacy doses the medication. The DON stated that process for monitoring trough was that the lab will call the facility and fax results to the resident's electronic health record, integrated with pharmacy. Then pharmacy will make their recommendation of what the patient needs. The DON said that the risk of elevated trough included renal issues, toxicity, and ringing in the ears. Her expectations were to notify the provider, which was "sometimes" charted, get orders from provider, and make sure pharmacy is aware since they dose the medication. The DON stated that if communication with the provider or pharmacy was not charted, the communication "probably" happened. The DON verified that the vancomycin trough levels for resident #215 was approximately 49, which she stated was extremely high. She stated that resident #215's nurse working that day [July 21, 2023] received the report. The DON said that lab will call the facility and ask for the nurse for the resident and report the lab value of the patient. The DON verified resident's records that there was no documentation that the provider or pharmacy were notified immediately after receiving the critical lab value. The DON stated that there was a note from the Nurse Practitioner on July 24, 2023 and stated, "but that is late." The DON verified the MAR that there were no changes on the vancomycin dosage after July 21, 2023 and that medication was never held after July 21, 2023. The DON stated that a staff was written up for not verifying lab values before the administration of vancomycin to resident #215. The DON provided staff record titled, "On the Job Training" for staff #84 that noted that staff failed to confirm lab value prior to administering medications and that she was educated on lab values particularly vancomycin trough and the contraindications when elevated.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan for bathing was implemented for one resident (#17). The deficient practice could result in residents developing skin issues and poor hygiene.

Findings include:

Resident #17 was admitted on August 20, 2019, with diagnosis that included multiple sclerosis and functional quadriplegia.

A Minimum Data Set (MDS) assessment dated June 1, 2023, included a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively intact. It also included that the resident needed one to two-person extensive assistance with personal hygiene, one-person physical assistance with bathing, extensive assistance with dressing and total dependence with Hoyer lift transfers.

Review of care plan initiated on June 15, 2023, included resident is totally dependent on dressing and transfers, but did not reveal a care plan for bathing.

Review of the Case Area Assessment (CAA) dated August 30, 2023, included that the resident was totally dependent in the area of bathing.

An interview was conducted with the MDS Coordinator (staff #7) on September 09/12/23 at 9:54 AM. Staff #7 stated that if a resident requires any assistance with bathing or assistive devices, it should be included in the care plan. Staff #7 reviewed the care plan for resident #17 and stated that there was no care plan for bathing.

An interview was conducted with the Director of Nursing (DON/staff #12) on September 12, 2023 at 11:01 AM. Staff #12 stated that showers are scheduled twice a week for each resident. She acknowledged that resident #17 needed assistance with showers and it should have been care planned. Staff #12 reviewed the care plan and stated that there was not a care plan for bathing.

The facility's policy "Nursing Administration" dated August 2012 and revised May 2023 stated that the baseline care plan will include minimal healthcare information necessary to properly care for a resident.

Based on clinical record review, interviews, policy and procedure, and observation of current practice, the facility failed to ensure on resident (#215) received treatment and care in accordance with professional standards.

Findings included:

Resident #215 was initially admitted to the facility on December 14, 2022 and readmitted on July 16, 2013 with diagnoses that included atherosclerotic heart disease of native coronary artery without angina pectoris, acute on chronic combined systolic and diastolic heart failure.

A hospital discharge summary dated July 16, 2023 revealed resident was discharged with a diagnosis of osteomyelitis. Instructions stated if resident is on vancomycin, then Vancomycin trough on day #3, then weekly after is checked, keep the level between 15 and 20, and Skilled Nursing Facility Pharmacist to dose per their protocol.

Review of the physician order revealed an order for vancomycin hydrochloride intravenous solution 500 milligram (mg)/100 milliliter (ml) to use 1.25 mg intravenously one time a day for osteomyelitis for 8 weeks initiated on July 16, 2023. Review of a progress note dated July 16, 2023 regarding the above order that the dose failed a general dose range check based on drug inputs and/or information provided and that the drug's dose should be adjusted based on renal function.

The physician order also revealed an order for vancomycin trough one time only for 1 day to draw 30 minutes prior to the 4th dose, initiated on July 20, 2023.

The medication was transcribed in the MAR (Medication Administration Record) and revealed vancomycin hydrochloride was administered from July 17, 2023 to July 23, 2023. In addition, the vancomycin trough was marked as complete on July 21, 2023 at 8:27 AM.

A lab results reported on July 21, 2023 at 3:02 PM revealed a vancomycin serum trough level of 49.6 microgram (?g)/mL, which was flagged as a critical result. The report stated the result was called to the facility on July 21, 2023 at 6:27 PM.

Review of records revealed no documentation that the pharmacy or the physician was notified upon receipt of the critical lab result.

A progress note dated July 24, 2023 at 6:20 AM stated the patient was found unresponsive and cardiopulmonary resuscitation was initiated. The noted also stated the resident had a time of death at 6:58 AM in the hospital.

An interview was conducted on September 12, 2023 at 12:31 PM with an LPN (Licensed Practical Nurse/Staff #60 who stated vancomycin trough was monitored for residents who are on vancomycin because the medication was a "harsh chemical" for the body. Staff #60 stated that trough is regulated every 4th dose to maintain certain level, drawn before the 4th dose and the dose adjusted if necessary. Staff #60 stated that if trough is elevated then the Assistant Directors of Nursing (ADON) are notified, who then notifies the Director of Nursing, who will reach out to the provider and wait for instructions to either change the dose or hold the medication. The LPN (staff #60) stated that the provider is notified because they are "medicine" and their purview. Further, he stated that he would reach out to the ADON and inform them of the labs and help navigate and would hold the next dose until he receives clarification. When asked what the risks were for giving the next dose when trough levels were high, staff #60 stated he was unsure but his next action was to notify the physician.

An interview was conducted on September 12, 2023 at 12:42 PM with an ADON (staff #102) who stated that trough levels were monitored for residents being treated with vancomycin. He said that depending on the infectious disease provider what is monitored such as kidney functions and other labs. The ADON stated that pharmacy monitored and adjusted the dose for vancomycin for therapeutic levels. Further, before the resident received the next dose, pharmacy would give recommendation on the dosage. The ADON stated that if there were reports of elevated trough level then the next action would be to notify pharmacy to fully integrate and get the next dosage. He stated that the medication was not skipped until guidance from pharmacy was received. Staff #102 said if the trough level was critically high or low, the provider was notified immediately and get orders. Further, he stated that the medication is not held but actions were based on the provider's instructions. He stated, the notification was noted on the resident's record as either lab, change of condition, change to order, and recommendation from pharmacy. Per the ADON, the normal level for trough was on the high end of 15 and if it was elevated it was up to pharmacy's discretion, per provider order. He stated that the risk of not notifying the provider of elevated trough was that the resident can experience side effects of red man's syndrome. In addition, his expectation was to notify the provider for high lab results because it could affect kidneys-vancomycin toxicity.

An interview conducted on September 12, 2023 at 1:05 PM with the DON (Director of Nursing/Staff #12) who stated that when a resident was receiving vancomycin, trough, weekly labs, and toxicity levels were monitored and managed by pharmacy. The DON stated that staff drew the labs and pharmacy doses the medication. The DON stated that process for monitoring trough was that the lab will call the facility and fax results to the resident's electronic health record, integrated with pharmacy. Then pharmacy will make their recommendation of what the patient needs. The DON said that the risk of elevated trough included renal issues, toxicity, and ringing in the ears. Her expectations were to notify the provider, which was "sometimes" charted, get orders from provider, and make sure pharmacy is aware since they dose the medication. The DON stated that if communication with the provider or pharmacy was not charted, the communication "probably" happened. The DON verified that the vancomycin trough levels for resident #215 was approximately 49, which she stated was extremely high. She stated that resident #215's nurse working that day [July 21, 2023] received the report. The DON said that lab will call the facility and ask for the nurse for the resident and report the lab value of the patient. The DON verified resident's records that there was no documentation that the provider or pharmacy were notified immediately after receiving the critical lab value. The DON stated that there was a note from the Nurse Practitioner on July 24, 2023 and stated, "but that is late." The DON verified the MAR that there were no changes on the vancomycin dosage after July 21, 2023 and that medication was never held after July 21, 2023. The DON stated that a staff was written up for not verifying lab values before the administration of vancomycin to resident #215. The DON provided staff record titled, "On the Job Training" for staff #84 that noted that staff failed to confirm lab value prior to administering medications and that she was educated on lab values particularly vancomycin trough and the contraindications when elevated.

Based on observations, staff interviews, and facility policy and procedures, the facility failed to ensure chemicals were safely stored. The deficient practice could result in residents being physically injured.

Findings include:

During the initial tour of the kitchen conducted on September 11, 2023 at 9:00 a.m. with the dietary supervisor (#11), chemicals were observed being stored on an open shelf in the kitchen to the right of the dishwasher. Staff #11 stated that they were not using the chemicals and he didn't know why they were on the shelf or who put them there, but he is responsible for ensuring that chemicals are secured. He also stated that as long as the kitchen door, located directly to the left of the dishwasher, leading to the dining room is closed and kitchen staff are present, it is alright to store the chemicals on the lower shelf. During this time, the kitchen door was observed to be open. The chemicals observed on the shelf included:
-Sure Clean Aerosol Cleaner
-Ajax Oxygen Bleach Cleaner
-Ecolab Keystone Glass Cleaner
-Ecolab Virasept Disinfectant
-Ecolab Monogram Clean Force Delimer
-Gen X Flatware Presoak
-Shine-Up Lemon Furniture Polish
-De-Scale Ultra Cleaner
-Comet Cleaner with Bleach
-Stainless Steel Aerosol Cleaner
-Watermark Fabulous Apple Air Freshener
-Sha-Brz Odorant
-HDIC Ultra Cleaner
-Airkem Vivid Glass Cleaner
-Orange Force Multi-Surface Cleaner Degreaser
-A spray bottle with no label containing approximately 3 ounces of a clear liquid that smelled like a chemical.
-A spray bottle with no label containing more than 24 ounces of a red/orange colored chemical.

An interview was conducted on September 14, 2023 at 8:28 a.m. with the Administrator (#188), who stated that he oversees the campus and supervisors the dietary supervisor. He stated that it is his expectation that staff follow the facility policy about safely securing and storing chemicals. He stated that the door leading from the dining room to the kitchen is not always locked and sometimes it is open because staff are doing things and coming and going.

The facility's policy, "Chemical Storage" dated January 2023 states that it is the policy of this facility that all products containing a hazardous chemical or substance will be properly labeled for use by employees and stored in a secured manner to ensure a safe, hazard free environment for residents.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value.

Findings include:

During the initial tour of the kitchen conducted on September 11, 2023 at 9:00 a.m. with the Dietary Supervisor (#11), the following observations were made in the large walk-in refrigerator and freezer:

-a full pan of diced cantaloupe, honeydew melon, and watermelon with a discard date of September 13. 2023 in the walk-in refrigerator was covered with Saranwrap and there was a hole approximately two by two inches in size located at one corner of the pan.

-a gallon size plastic bag of mixed salad with a discard date of September 13, 2023 was not sealed and some of the salad was brown and wilted.

-a frozen bag containing 17 to 18 hash browns not sealed.

Staff #11 stated that the purpose of covering/sealing food is to maintain freshness, prevent contamination from other food particles, prevent freezer burn, and maintain the quality of taste.

An interview was conducted on September 14, 2023 at 8:28 a.m. with the Administrator (#188), who stated that he oversees the campus and supervises the dietary supervisor. He stated that food should be covered with saran wrap or put in a bag and sealed. He stated that the purpose for sealing food is to preserve freshness.

The facility's policy, "Alta Mesa Health and Rehab, Policy & Procedure Manual Food Storage" states that food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated.

Based on clinical record review, staff interviews, and policy and procedures, the facility failed to ensure that a care plan for bathing was implemented for one resident (#17). The deficient practice could result in residents developing skin issues and poor hygiene.

Findings include:

Resident #17 was admitted on August 20, 2019, with diagnosis that included multiple sclerosis and functional quadriplegia.

A Minimum Data Set (MDS) assessment dated June 1, 2023, included a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident was cognitively intact. It also included that the resident needed one to two-person extensive assistance with personal hygiene, one-person physical assistance with bathing, extensive assistance with dressing and total dependence with Hoyer lift transfers.

Review of care plan initiated on June 15, 2023, included resident is totally dependent on dressing and transfers, but did not reveal a care plan for bathing.

Review of the Case Area Assessment (CAA) dated August 30, 2023, included that the resident was totally dependent in the area of bathing.

An interview was conducted with the MDS Coordinator (staff #7) on September 09/12/23 at 9:54 am. Staff #7 stated that if a resident requires any assistance with bathing or assistive devices, it should be included in the care plan. Staff #7 reviewed the care plan for resident #17 and stated that there was no care plan for bathing.

An interview was conducted with the Director of Nursing (DON/staff #12) on September 12, 2023 at 11:01 am. Staff #12 stated that showers are scheduled twice a week for each resident. She acknowledged that resident #17 needed assistance with showers and it should have been care planned. Staff #12 reviewed the care plan and stated that there was not a care plan for bathing.

The facility's policy "Nursing Administration" dated August 2012 and revised May 2023 stated that the baseline care plan will include minimal healthcare information necessary to properly care for a resident.

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that food was properly stored. The deficient practice could result in a loss of freshness, freezer burn, taste, and loss of nutritive value.

Findings include:

During the initial tour of the kitchen conducted on September 11, 2023 at 9:00 a.m. with the Dietary Supervisor (#11), the following observations were made in the large walk-in refrigerator and freezer:

-a full pan of diced cantaloupe, honeydew melon, and watermelon with a discard date of September 13. 2023 in the walk-in refrigerator was covered with Saranwrap and there was a hole approximately two by two inches in size located at one corner of the pan.

-a gallon size plastic bag of mixed salad with a discard date of September 13, 2023 was not sealed and some of the salad was brown and wilted.

-a frozen bag containing 17 to 18 hash browns not sealed.

Staff #11 stated that the purpose of covering/sealing food is to maintain freshness, prevent contamination from other food particles, prevent freezer burn, and maintain the quality of taste.

An interview was conducted on September 14, 2023 at 8:28 a.m. with the Administrator (#188), who stated that he oversees the campus and supervises the dietary supervisor. He stated that food should be covered with saran wrap or put in a bag and sealed. He stated that the purpose for sealing food is to preserve freshness.

The facility's policy, "Alta Mesa Health and Rehab, Policy & Procedure Manual Food Storage" states that food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated.

Based on observations, staff interviews, and facility policy and procedures, the facility failed to ensure chemicals were safely stored. The deficient practice could result in residents being physically injured.

Findings include:

During the initial tour of the kitchen conducted on September 11, 2023 at 9:00 a.m. with the dietary supervisor (#11), chemicals were observed being stored on an open shelf in the kitchen to the right of the dishwasher. Staff #11 stated that they were not using the chemicals and he didn't know why they were on the shelf or who put them there, but he is responsible for ensuring that chemicals are secured. He also stated that as long as the kitchen door, located directly to the left of the dishwasher, leading to the dining room is closed and kitchen staff are present, it is alright to store the chemicals on the lower shelf. During this time, the kitchen door was observed to be open. The chemicals observed on the shelf included:
-Sure Clean Aerosol Cleaner
-Ajax Oxygen Bleach Cleaner
-Ecolab Keystone Glass Cleaner
-Ecolab Virasept Disinfectant
-Ecolab Monogram Clean Force Delimer
-Gen X Flatware Presoak
-Shine-Up Lemon Furniture Polish
-De-Scale Ultra Cleaner
-Comet Cleaner with Bleach
-Stainless Steel Aerosol Cleaner
-Watermark Fabulous Apple Air Freshener
-Sha-Brz Odorant
-HDIC Ultra Cleaner
-Airkem Vivid Glass Cleaner
-Orange Force Multi-Surface Cleaner Degreaser
-A spray bottle with no label containing approximately 3 ounces of a clear liquid that smelled like a chemical.
-A spray bottle with no label containing more than 24 ounces of a red/orange colored chemical.

An interview was conducted on September 14, 2023 at 8:28 a.m. with the Administrator (#188), who stated that he oversees the campus and supervisors the dietary supervisor. He stated that it is his expectation that staff follow the facility policy about safely securing and storing chemicals. He stated that the door leading from the dining room to the kitchen is not always locked and sometimes it is open because staff are doing things and coming and going.

The facility's policy, "Chemical Storage" dated January 2023 states that it is the policy of this facility that all products containing a hazardous chemical or substance will be properly labeled for use by employees and stored in a secured manner to ensure a safe, hazard free environment for residents.