Skyline Healthcare Center - La

DON stated the Interdisciplinary Team (IDT, a group of professional and direct care staff that have

of the resident before it gets implemented.

The DON stated not keeping the call light within the reach

A review of the facility's recent policy and procedure titled, Communication- Call System, last reviewed on 4/4/2024, indicated to provide a mechanism for residents to promptly communicate with Nursing Staff.

Call cords will be placed within the resident's reach in the resident's room.

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floor cleaning procedures include vacuuming or sweeping the floor thoroughly, paying close attention

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indicated to ensure that all restraints are used properly and only, when necessary, on residents at the

resident lacks medical decision-making capacity, the Licensed Nurse will verify that informed

resident's condition necessitates. If the IDT- Restraint Reduction Committee determines that restraints are necessary, it will recommend the issuance of an attending physician's order. In such a case, the initial attending physician order for a restraint will not exceed 14 days. A physician restraint means the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and that is used as a behavioral restraint.

Unless otherwise specified by the attending physician's order, alternative methods of behavioral control must be attempted and documented in the resident's medical record before a physical restraint is used.

A review of the facility's recent policy and procedure titled, Bed Rail, last reviewed on 4/4/2024, indicated to provide guidance to adequately evaluate the use of bed rails and prevent potential entrapment or other safety hazards.

Prior to installation, assess the resident's risk of entrapment with bed rails.

Review the risk and benefits of bed rails with the resident and resident's representative and obtain informed consent prior to installation.

Follow manufacturers' recommendations and specifications for installing and maintaining the bed rails.

Bed rails cannot be used for staff convenience or as discipline, such as prevention of falls when less effective methods have not been attempted or ruled out. A detailed order by a healthcare provider (e.g., a physician, nurse practitioner) is required before any restraints can be utilized.

Prior to the installation of bed rails, the ordering physician will obtain informed consent from the resident or their representative.

The licensed nurse will initiate a care plan around the use of bed rails.

A review of the facility provided manufacturer's FAB 1 (Includes One Assist Bar and Hardware Bag), dated 8/2014, indicated when assessing the risk of entrapment, you need to consider your bed, mattress, headboard and footboard, assist devices (i.e. rails and assist bars) and other accessories as an entire system.

All bed systems are evaluated for full compliance to the FDA/CDRH Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment guidelines.

A review of the facility provided manufacturer's guideline BF 1, dated 8/2014, indicated the guidelines set forth by the FDA Guidance layout specific dimensional limitations on potentially injury-threatening gaps and spaces that can occur between bed system components, such as rails, when not properly installed.

However, entrapment issues can often arise when a healthcare provider/facility has not correctly assembled the components on a bed. It is essential that the provider/facility fully understand their responsibility in complying to the guidelines set forth by the FDA in order to avoid injury.

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reviewed 4/4/2024, indicated before the transfer or discharge occurs, the facility must notify the

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During a concurrent interview and record review on 6/13/2024, at 9:57 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 33's Order Summary Report and Bed Hold Agreement Form. RN 1 stated there was an order for 7-day bed hold for the resident prior to transfer to GACH 1. RN 1 stated the Bed Hold Agreement was not completed and provided to the resident when the resident was transferred to GACH 1 on 6/4/2024. RN 1 stated it was important to provide the 7-day bed hold agreement to the resident to inform and reassure the resident that the bed will be held for the resident for 7 days.

During an interview on 6/13/2024, at 6:30 p.m., with the Director of Nursing (DON), the DON stated Notification of Bed Hold option should have been completed and provided to the resident and their representative upon transfer/therapeutic leave to inform them that their bed is being held for 7 days.

A review of the facility's recent policy and procedure titled, Bed Hold, last reviewed on 4/4/2024, indicated the facility notifies the resident and/or representative, in writing, of the bed hold, option, any time the resident is transferred to an acute care hospital or requests therapeutic leave.

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During an interview on 6/13/2024 at 3:05 p.m. with MDSC, MDSC stated the information on the MDS assessments was submitted to the Federal database. MDSC stated incorrect information for Resident 7 was sent to the Federal database.

A review of the facility's policy and procedure (P&P) titled, RAI Process: Operational Manual - Administrative Policies, revised 10/4/2016, indicated the resident-assessment should accurately depict and identify resident-specific issues.

The P&P also indicated the facility would accurately assess each resident's functional capacity and health status.

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During the comprehensive assessment period the ID members will assess the Resident's safety risk (e.g. smoking, self-administration of medication) as well as any other Resident specific safety risks.

After a risk evaluation is completed, a Resident centered care plan will be developed to mitigate safety risk factors.

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reviewed and revised at the following times:

ii.

Change of condition; iii.

In preparation for discharge; iv.

To address changes in behavior and care; and v.

Other times as appropriate or necessary.

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During a concurrent interview and record review on 6/11/2024, at 2:13 p.m., with Licensed Vocational Nurse 6 (LVN 6), reviewed Resident 6's Order Summary Report and the Location of Administration site of insulin from 1/2024 to 6/2024 of. LVN 6 stated there were multiple occasions that the insulin administration was repeatedly given on the same site. LVN 6 stated the sites of insulin administration should be rotated to prevent skin irritation and lipodystrophy.

During an interview on 6/13/2024, at 6:26 p.m., with the Director of Nursing (DON), the DON stated insulin sites of administration should be rotated to prevent skin lumps and discoloration on residents.

A review of the facility provided manufacturer's guideline- Novolog FlexPen (insulin aspart injection) 100 units/ml, undated, indicated to rotate injections between injection spots #1-4 in the diagram at to the right: stomach, thighs, upper arms, and buttocks.

A review of the facility provided manufacturer's guideline- Novolog insulin aspart injection 100 unit/ml, with initial U.S. approval in 2000, indicated to rotate injection sites within the same region from one injection to the nest to reduce risks of lipodystrophy and localized cutaneous amyloidosis.

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During an observation on 6/12/2024 at 12:11 p.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed.

During an observation on 6/13/2024 at 8:58 a.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed.

During an interview on 6/13/2024 at 9:03 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 7's shower days were on Monday and Thursday. CNA 1 stated Resident 7 received a bed bath on Monday and will receive a bed bath today. CNA 1 stated Resident 7 did not receive showers because it was difficult and caused Resident 7 pain to position Resident 7 in the shower chair.

During an interview on 6/13/2024 at 10:42 a.m. with CNA 1, CNA 1 stated Resident 7 wore a hospital gown because Resident 7 was usually in bed. CNA 1 stated Resident 7 was dressed in regular clothes when the family came to visit and when Resident 7 was transferred into a special type of chair.

During an interview on 6/13/2024 at 3:42 p.m. with the Director of Nursing (DON), the DON stated Resident 7 did not have any care plans preventing Resident 7 from getting out of the bed.

The DON stated Resident 7 was alert and should not be in bed.

The DON stated the facility was not maintaining Resident 7's mobility and quality of life while Resident 7 remained in bed.

During a concurrent interview and record review on 6/13/2024 at 5:13 p.m. with the Activity Assistant (AA), AA reviewed Resident 7's activity log from 1/2024 to 6/2024 and stated Resident 7 was seen for activities in the bedroom. AA stated the purpose of the activity program was to assist the residents (in general) with participation, communication, and cognitive function. AA did not know the reason Resident 7 was not assisted out to the activity room and stated, I can't imagine lying in bed all day.

A review of the facility's policy and procedure (P&P) titled, Resident Rights - Quality of Life, revised 2017, indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.

The P&P also indicated resident were encouraged and assisted to dress in their own clothes rather than in hospital gowns.

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acceptable.

respirations unless a Code Status (means the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) prohibits CPR.

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reviewed and revised, as necessary, at least quarterly, or more often if change of condition occurs.

reviewed on 4/4/2024, indicated the resident will be reassessed via MDS by the Activity Coordinator

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During a concurrent interview and record review on 6/12/2024 at 2:25 p.m. with the Director of Rehabilitation (DOR), Resident 7's OT Evaluation, dated 2/15/2024, and OT Discharge summary, dated [DATE], were reviewed.

The DOR stated Resident 7 received an OT Evaluation, dated 2/15/2024, after Resident 7's hospitalization.

The DOR stated the OT Evaluation indicated Resident 7's had limited ROM in both shoulders, both elbows, and both wrists.

The DOR stated Resident 7 tolerated wearing both hand rolls and a right elbow splint for five hours.

The DOR stated Resident 7's OT Discharge summary, dated [DATE], included recommendations for RNA to provide PROM to both arms, to apply both hand splints, and to apply the right elbow splint.

The DOR stated there were no OT recommendations for the RNA to apply a left elbow splint.

The DOR stated splints provided to a resident (in general) required an assessment to ensure the splint was an appropriate fit for the resident since the splint could cause skin breakdown.

A review of a textbook titled, Occupational Therapy for Physical Dysfunction, fifth edition, published 2002, page 316, indicated the OT's role was to evaluate the need for a splint clinically and functionally; to select the most appropriate splint; to provide or fabricate (make) the splint; to assess the fit of the splint; to teach the patient and caregivers the purpose, care, and use of the splint.

The Occupational Therapy for Physical Dysfunction textbook, page 316, further indicated the OT must consider, carefully monitor, and teach the patient and caregiver to report any of these problems related to orthotic use, including impaired skin integrity, pain, and swelling.

A review of the facility's policy and procedure titled, Restorative Nursing Program Guidelines: Nursing Manual - Restorative Nursing Program, revised 9/19/2019, indicated the RNA should carry out the restorative program according to the care plan.

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Firm or press Auto Firm on the touch panel each time the mattress is first inflated.

Users can then

A review of the facility provided manufacturer's guideline for LALM 2, undated, indicated patient

patient comfort pressure levels from 0 to 9 and provides a guide to the caregiver to set approximate comfort pressure level depending on the patient weight.

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During an observation on 6/13/2024 at 3:13 p.m. in Resident 7's bedroom with Physical Therapist 1 (PT 1), Resident 7 was awake while lying in bed. PT 1 described Resident 7's arms as contracted at both shoulders and elbows. PT 1 attempted but was unable to fully extend Resident 7's right-hand fingers. Resident 7 winced due to pain during PT 1's attempts to extend the right-hand fingers. PT 1 attempted to perform ROM to Resident 7's left arm but Resident 7 resisted PT 1's attempts.

A review of the facility's policy and procedure (P&P) titled, Range of Motion Exercise Guidelines: Nursing Manual - Restorative Nursing Program, revised 1/1/2012, indicated the facility would maintain or increase ROM of the joint and to prevent or decrease contractures.

A review of the facility's P&P titled, Restorative Nursing Program Guidelines, revised 9/19/2019, indicated the Restorative Nursing Program included nursing interventions that promote a patient's ability to attain, and maintain his/her optimal functional potential.

Restorative care implies that the possibility for progress exists, and that improvement can be expected, or there is a risk of imminent decline which can be prevented.

A review of the facility's P&P titled, Rehab Rounding and Screening: Rehabilitation Services, revised 7/22/2021, indicated the purpose of the P&P included to identify residents with changes and to allow those residents to receive therapy services if functional decline or improved are present.

The P&P indicated screening did not require objective data and assessments.

During an interview on 6/13/2024 at 7:05 p.m. with the Administrator (ADM), the ADM stated the facility did not have a general ROM policy which did not include Restorative Nursing since all residents were provided RNA if they were not receiving therapy.

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During a concurrent observation and interview with Resident 80, on 6/11/2024, at 10:30 a.m., in the outside patio, Resident 80 sat in a wheelchair with a cigarette box on the left side of the resident's wheelchair. Resident 80 stated he smokes and stated he has made arrangements with the facility for him to keep his smoking materials with him.

During an observation on 6/13/2024, at 3:54 p.m., inside Resident 80's room, Resident 80 was lying down in bed with two cigarette boxes on a bedside table adjacent to the resident's bed.

During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 4, on 6/13/2024, at 4:33 p.m., Resident 80's care plans, dated 3/11/2024, was reviewed and LVN 4 confirmed Resident 80's care plan does not indicate where Resident 80 can store their smoking supplies. LVN 4 stated Resident 80's care plan is too broad and not specific and should be specific to determine how to deal with certain situations. LVN 4 stated care plans guide nurses on what to do and if it was not specific, the nursing staff would not be able to determine where to store the resident's smoking supplies. LVN 4 reviewed Resident 80's medical record and confirmed Resident 80 did not have a smoking and safety assessment performed on admission and stated Resident 80 should have had an assessment performed on admission to evaluate if the resident was safe enough to smoke and to determine what interventions will be used. LVN 4 further stated residents are not allowed to keep cigarettes or lighters with them due to resident safety and because residents can potentially injure themselves or others.

During an interview with the Director of Nursing (DON), on 6/13/2024, at 6:14 p.m., the DON stated Resident 80 is a smoker.

The DON stated smoking and safety assessments are conducted on admission, quarterly, and when there is a significant change.

The DON stated residents smoking materials should not be kept in the resident rooms and should be kept in the social services department's office.

The DON stated the resident's care plan should indicate the location where smoking material is kept because if residents are allowed to keep their smoking material, the facility should know where it is kept.

The DON further stated if the facility is not aware of where a resident stores their smoking material, there is a potential for burn injuries, smoking inside the rooms, or starting a fire from improper disposal.

A review of the facility's policy and procedure (P&P) titled, Smoking by Residents, last reviewed 4/4/2024, indicated residents who express a desire to smoke are assessed for safety when a resident initially expresses a desire to smoke, upon admission, quarterly, upon significant change of condition, and annually.

The P&P indicated smoking paraphernalia will be stored by facility staff.

The P&P further indicated the interdisciplinary team will develop and individualized plan for safe storage, use of smoking materials, assistance and required supervision for residents who smoke.

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During a concurrent observation and interview on 6/11/2024, at 9:10 a.m., with Certified Nursing Assistant 2 (CNA 2), inside Resident 6's room, observed the resident's urinary catheter drainage bag touching the floor. CNA 3 stated the urinary catheter drainage bag should be kept off the floor to prevent infection to the resident.

During an interview on 6/13/2024, at 6:30 p.m., with the Director of Nursing (DON), the DON stated the urinary catheter bag should be kept off the floor to prevent ascending infection (the most common route by which bacteria gain access into the urinary tract) to the resident.

The DON further stated the bag was touching the floor could also cause accidents such as slips, trips, and falls to the residents and the staff and could result in dislodgement of the urinary catheter.

A review of the facility's recent policy and procedure titled, Catheter- Care of, last reviewed on 4/4/2024, indicated the catheter tubing, bag or spigot will be anchored to not touch the floor.

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water before administering medication.

indicated:

I.

A medication administration error occurs when a resident receives a dose of medication that deviates from the original physician's order and/or established facility policy and procedures.

Types of errors include:

• Incorrect administration technique.

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facility should have a process of ensuring the nebulizer machines are working properly.

The DON

hours of use before replacement.

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During an interview with Licensed Vocational Nurse (LVN) 1, on 6/11/2024, at 9:58 a.m., LVN 1 stated she was assigned to Resident 21 and that Resident 21 went to dialysis every Tuesday, Wednesday, Thursday, and Saturday.

During an interview with Resident 21, on 6/11/2024, at 3:55 p.m., Resident 21 stated he had just returned from dialysis and that he goes to the dialysis clinic every Tuesday, Wednesday, Thursday, and Saturday.

During a concurrent interview and record review with LVN 4, on 6/13/2024, at 4:33 p.m., Resident 21's care plan, last revised 4/29/2024, was reviewed and LVN 4 confirmed the care plan did not indicate Resident 21's scheduled Wednesday dialysis session. LVN 4 stated Resident 21 goes to dialysis every Tuesday, Wednesday, Thursday, and Saturday. LVN 4 stated Resident 21's care plan should be revised to include his Wednesday dialysis sessions so that the facility staff knows what the resident's schedule is in case there is a change of condition, and the right information can be provided to the physician. LVN 4 further stated care plans are revised quarterly and during significant changes.

During an interview with the Director of Nursing (DON), on 6/13/2024, at 6:14 p.m., the DON stated Resident 21 gets dialysis treatments.

The DON stated Resident 21's care plan should include the resident's dialysis days so that the staff would know what days the resident receives dialysis, and the resident can receive pre- and post-dialysis treatments on the specified days.

The DON further stated if the care plan is not revised, the facility staff would not be aware of the care to provide to the resident.

A review of the facility's policy and procedure (P&P) titled, Dialysis Care, last reviewed 4/4/2024, indicated the interdisciplinary team will ensure that the resident's care plan includes documentation of the resident's renal condition and necessary precautions (e.g., shunt site, weights, dietary and fluid restrictions, no blood pressure on affected side, lab draws, IV, injection on arm with shunt, observe for signs and symptoms of infection, etc.).

The P&P further indicated the resident's care plan will be updated as needed.

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the ordering physician will obtain informed consent from the resident or their representative.

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During a concurrent interview and record review on 6/13/2023 at 4:41 p.m., with Infection Preventionist (IP), reviewed CNA 5's employee file.

The IP stated the last performance evaluation (PE) filed for CNA 5 was dated 4/18/2023.

The IP verified CNA 5's PE for the year 2023 was missing.

During an interview on 6/13/2024 at 7:15 p.m., with the Director of Nursing (DON), the DON stated performance evaluations are done annually.

The DON stated the Director of Staff Development is responsible for completing the CNA's performance evaluation.

The DON stated the purpose of doing PE was to inform the employees of their performance progress and discuss areas in their performance that may need improvement and to evaluate the staff's competency in performing their job responsibilities.

A review of the facility's policy and procedure titled, Staff Competency Assessment, last reviewed 4/4/2024, indicated: - the purpose of completing competency assessments is to determine knowledge and/or performance or assigned responsibilities based on standard of practice, policy and procedure and regulatory requirement. - Competency assessment will be performed upon hire during the employee's 90-day employment period, annually or as needed. - Competency assessments will be through written testing and/or observations, whichever is appropriate.

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During a review of the MAR ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], on 6/11/2024 at 11:48 AM, the MAR indicated Resident 11's dose of apixaban 5 mg was due every day at 9 AM and 5 PM, and there was no documentation for the apixaban 5 mg administration on 6/11/2024 for the 9 AM dose.

Review of the pharmacy facsimile manifests, the pharmacy received a request to refill Resident 11's apixaban 5 mg tablets from the facility on 6/11/2024 at 9:39 AM.

Review of the facility's policy and procedures (P&P), titled Medication Administration, dated 1/1/2012, the P&P indicated: B.

The Licensed Nurse will prepare medications within one hour of administration. i.

Medications may be administered one hour before or after the scheduled medication administration time.

Review of the facility's P&P, titled Reordering, Changin, and Discontinuing Medication Orders, dated 4/4/2024, the P&P indicated that: The facility will communicate any medication reorders, changes, or discontinuations to the pharmacy in accordance with pharmacy guidelines and state / federal regulations; thus ensuing standardized process of communication.

B.

Reorder / Refill orders:

• Refills can be requested via facilities EMAR system; this is the most preferred method.

Facility may also request refills by placing the 'refill strip portion of the medication label on the Refill Order Form and faxing it to the pharmacy.

Review of the facility's P&P titled, Medication Ordering and Prescribing Reorders, dated 4/4/2024, the P&P indicated To ensure resident's received medications in a timely fashion.

• Nurse will examine supply of medication remaining to ascertain when a reorder/refill is needed for the

resident. As a guidance, reorder medications when a four (4) day supply remains.

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intended as a guide, not an all-inclusive list.

Any questions should be addressed through pharmacy

• Time-Release Tablets - Designed to release medication over a period of 8 to 12 hours.

Some formulations are designed to reduce gastric irritation.

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Review of facility's guide, [untitled] dated [DATE], the guide listed the following:

Insulin products (except Levemir, Novolin R, Novolin N, Novolin 70/30) - Store unopened vials in the refrigerator.

May store opened vials at room temperature or in the refrigerator.

Discard 28 days after opening or removed from refrigeration.

Novolin R, Novolin N, Novolin 70/30 - Store unopened vials in the refrigerator.

Store opened vials at room temperature.

Discard 42 days after opening.

Insulin pens and cartridges - Store at room temperature and do not refrigerate after opening.

Expiration dates vary by manufacturer.

Review of facility's P&P, titled Medication Return and Disposal of Medications, dated [DATE], the P&P indicated: To provide a process for removing medications from the medication area when necessary.

I.

Discontinued medications that are not returnable to the pharmacy for credit will be removed from the medication area and destroyed.

• All medications that are discontinued or expired will be removed from the resident's tray,

medication or treatment cart, refrigerator, medication room or other place of storage.

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that are designed and worn to effectively keep the hair from contacting exposed food; clean

A review of Food Code 2017 section 2-3 Personal Cleanliness subpart 2-301.11 and 2-301.12 indicated employees shall keep their hands and exposed portions of their arms clean for at least 20 seconds, using a cleaning compound in a handwashing sink.

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During an observation on 6/12/2024 at 8:30 a.m. in Resident 19's bedroom with Restorative Nursing Aide 1 (RNA 1), Resident 19 was lying in bed with both elbows bent in a 90-degree angle, both hips bent to hip height, and both knees bent in a 90-degree angle. RNA 1 stood on Resident 19's right side and began PROM exercises to the right elbow. RNA 1 extended Resident 19's right elbow, which continued to be in a bent position. RNA 1 performed PROM to Resident 19's right shoulder, wrist, and hand. RNA 1 performed massage to Resident 19's right knee prior to providing PROM to the right leg at the hip and knee joints. RNA 1 extended Resident 19 right hip and knee, which did not completely extend, and remained in bent positions. RNA 1 moved to the left side of Resident 19's bed. RNA 1 performed PROM to Resident 19's left shoulder, wrist, hand but did not perform PROM to the left elbow, which continued to be in a bent position. RNA 1 performed massage to the left knee prior to providing PROM to Resident 19's left leg at the hip and knee joints. RNA 1 extended Resident 19's left hip and knee, which remained in bent positions. RNA 1 applied both elbow splints to Resident 19's arms.

During a concurrent interview and record review on 6/13/2024 at 11:19 a.m. with the DOR and Director of Nursing (DON), Resident 19's physician orders, dated 4/25/2024, for OT/PT evaluation and treatment were reviewed.

The DOR stated Resident 19 was seen for an OT evaluation but was not seen for a PT evaluation since Resident 19 was unable to walk.

The DOR stated Resident 19 could have PT needs even if Resident 19 was unable to walk.

The DON stated the PT evaluation should have been completed for Resident 19 if there was a physician order.

A review of the facility's job description titled Physical Therapist, revised 5/23/2019, indicated the PT evaluated and treated patients and documented the services in the medical record.

A review of the facility's policy and procedure (P&P) titled Quality of Care Compliance Requirements, revised 6/2016, indicated the facility had systems in place that reduce the likelihood of common risk areas associated with the delivery of quality care to facility residents.

The P&P indicated common risk areas may include the failure to provide appropriate therapy services.

The P&P indicated the provision of therapy was care planned by the clinical team under physician order

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with the legal scope of practice or restriction, and within established standards of care, policies, and

A review of the facility's policy and procedure (P&P) titled, Compliance with Laws and Professional

comply with State and Federal laws relating to the operation of the Facility and care of residents.

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During a concurrent interview and record review on 6/12/2024 at 8:10 a.m. with RNA 1, Resident 7's RNA flow sheet for 6/11/2024 was reviewed. RNA 1 stated she attempted to provide treatment to Resident 7 multiple times but Resident 7 refused due to pain. RNA 1 stated she applied Resident 7's knee splints from 4:30 p.m. to 7:00 p.m. (2 hours, 30 minutes). RNA 1 stated Resident 7's RNA documentation for 6/11/2024 was inaccurate since Resident 7 did not have both knee splints on for 4 hours. RNA 1 stated Resident 7's RNA documentation was inaccurate for 6/11/2024 because the documentation was completed prior to providing intervention to Resident 7.

During a concurrent interview and record review on 6/12/2024 at 12:30 p.m. with RNA 1, Resident 7's RNA flow sheet for 6/11/2024 was further reviewed. RNA 1 stated Resident 7's hand rolls and elbow splint were not applied on 6/11/2024. RNA 1 stated Resident 7's documentation on the RNA flow sheet for 6/11/2024 was inaccurate.

A review of the facility's policy and procedure (P&P) titled, Documentation: Nursing Manual - Restorative Nursing Program, revised 1/1/2012, indicated the Restorative Nursing Programs should be documented accurately and timely.

The P&P indicated the RNA will document the treatment provided daily and to initial the specific treatment provided to the resident.

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All healthcare professionals (HCP shall submit a progress note with a client signed time in sheet

- Provider agrees to comply with and conform to state and federal regulations.

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During an interview on 6/13/2024, at 6:30 p.m., with the DON, the DON stated the urinal should be labeled with the resident's room number and the date last changed for infection control.

A review of the facility's recent policy and procedure titled, Infection Control- Policies & Procedures, last reviewed on 4/4/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

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minimize the risk of residents acquiring, transmitting, or experiencing complications from influenza.

representative must give consent prior to receiving the vaccine.

They can refuse the immunization - with such refusal being noted in the resident's medical record.

The resident's medical record will include documentation that indicates: the resident or representative was provided education regarding the risk and benefits of the vaccine and whether the resident received the influenza vaccine, or refuses the vaccine.

A review of the facility policy and procedure titled, Pneumococcal Disease Prevention, last reviewed 4/4/2024, indicated the facility will offer pneumococcal immunization to each resident.

Pneumococcal vaccination is recommended for: adults [AGE] years old and greater; anyone 2 to [AGE] years old who has a long term health problem, anyone 2 to [AGE] years old who has a disease or condition that lowers the body's resistance to infection, anyone 2 to [AGE] years old sho is taking a drug or treatment tha lowers the body's resistance to infection, anyone 19 to [AGE] years old who is a smoker or has asthma, and residents of nursing home or long term care facilities.

The resident may refuse immunization, with such refusal being documented in the resident's medical record.

The resident's medical record shall include documentation that indicates: that the resident or representative was provided education regarding the benefits and potential side effects of the vaccine, a completed copy of the Pneumococcal Vaccination, Informed Consent or Refusal.

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Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

could be re-educated, and they may change their mind.

The IP stated the importance of offering,

(DON) reviewed the facility policy and procedures regarding COVID-19 vaccinations.

The DON stated residents are screened at admission and annually for the COVID-19 vaccine, consent is signed for the vaccination, and the vaccine is administered when appropriate.

The DON stated the facility policies and procedures for COVID-19 vaccinations were not followed for Resident 20.

The DON stated vaccine administration is important in the elderly population because they are higher risk for developing complications.

The DON stated if residents are not vaccinated, there is a risk COVID-19 could spread to other residents leading to complications resulting in hospitalization or a decline in function.

A review of the facility policy and procedure titled, COVID-19 Vaccination Program, last reviewed 4/4/2024, indicated the facility will offer SARS-CoV-2 vaccinations (including additional and booster doses) to all residents.

They will be encouraged but are not required to be vaccinated or boosted.

The staff member who presents the vaccination education materials to the resident or responsible party and receives the declination or agreement for the vaccine is the person responsible for documenting in the resident's medical record.

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Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

p.m., the facility's document titled, Re: Request for Room Waiver Size and Capacity, dated 6/12/2024,

minimal harm four residents.

The ADM stated the residents are respectable with each other and have not brought up concerns being in a five-person bedroom.

The ADM stated privacy is able to be maintained in the

changes to accommodate the residents.

A review of the facility's policy and procedure (P&P) titled, Room Waiver, last reviewed 4/4/2024, indicated residents will be screened for medical and personal needs for placement in waiver beds/rooms.

555117 06/13/2024

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

During the initial tour conducted on 6/11/2024 and multiple observations conducted throughout the recertification survey, the observations indicated the square footage of the rooms requested for waiver did not interfere with the care and services provided by the staff.

The residents observed had enough space to move about freely inside the rooms and there was enough space for residents' bed, dresser, and resident care equipment.

During the initial tour conducted on 6/11/2024 and multiple interviews with staff members throughout the recertification survey, the interviews indicated the facility staff had no issues or concerns related to space in residents' rooms and were able to conduct resident care with no issues.

During a concurrent observation and interview with Resident 293, on 6/13/2024, at 11:10 a.m., inside room [ROOM NUMBER], Resident 293 stated he had no concerns regarding the space he was allotted in his room. Resident 293 maneuvered himself around the room in a wheelchair with no issues related to space. Resident 293 appeared calm and in no distress.

During a concurrent interview and record review with the Administrator (ADM), on 6/13/2024, at 5:28 p.m., the facility's document titled, Re: Request for Room Waiver Size and Capacity, dated 6/12/2024, was reviewed and the ADM confirmed Rooms 2, 5, 6, 15, 19, 20, 21, 23, 24, 25, 26, 27, 28, 29, 30, and 33 had a square footage of less than 80 square feet per resident.

The ADM stated the residents have not brought up any concerns related to space in the room.

The ADM stated the staff are able to perform nursing care for the residents without issues.

The ADM further stated if a resident brings up concerns regarding the space in the room, the facility could do a room change to accommodate the residents.

A review of the facility's policy and procedure (P&P) titled, Room Waiver, last reviewed 4/4/2024, indicated residents will be screened for medical and personal needs for placement in waiver beds/rooms.

During a concurrent observation and interview on 6/11/2024, at 9:48 a.m., with Treatment Nurse 1 (TN 1), inside Resident 15's room, observed the resident's call light hanging on the wall and not within resident's reach. TN 1 stated it was the preference of the family member to have the call light not within the reach of the resident. TN 1was asked if there was a care plan addressing the resident's family's preference to not keep the call light within the resident's reach. TN 1 stated there was no care plan created to reflect the family member's preference to keep the call light away from the resident's reach.

During an interview on 6/13/2024, at 6:26 p.m., with the Director of Nursing (DON), the DON stated the call light should be within Resident 15's reach.

The DON stated she was only made aware of the family's preference of not keeping the call light within the resident's reach today (6/13/2024).

The DON stated the Interdisciplinary Team (IDT, a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a resident) should have met and discussed the family member's preference of not having the call light within the reach of the resident before it gets implemented.

The DON stated not keeping the call light within the reach of the resident could result to accidents such as falls.

555117

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555117 B.

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

During an observation on 6/11/2024, at 3:24 p.m., inside Resident 15's room, observed the resident lying down in bed with both upper bed side rails up.

555117

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555117 B.

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

• One of five sampled residents (Resident 295) observed for medication administration by failing to

administer Metoprolol Succinate (a medication used to treat high blood pressure) Extended Release ([ER]- a form of medication that is sustained (slowly) release) and Duloxetine (a medication used to treat depression) Delayed Release ([DR] - a form medication that is sustained release) according to manufacturer's recommendations.

These failures had the potential to result in Resident 295 to receive suboptimal (less than the highest standard or quality) care, experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) such as gastrointestinal ([GI] - relating to the stomach) irritation negatively impacting Resident 295's health and well-being.

Cross reference

During an observation on 6/12/2024 at 7:30 a.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed while Restorative Nursing Aide 1 (RNA 1) stood on the left side of the bed attempting to apply a left knee splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion).

During an observation on 6/12/2024 at 12:11 p.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed.

During an observation on 6/13/2024 at 8:58 a.m. in Resident 7's bedroom, Resident 7 wore a hospital gown while lying awake in bed.

During an interview on 6/13/2024 at 9:03 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 7's shower days were on Monday and Thursday. CNA 1 stated Resident 7 received a bed bath on Monday and will receive a bed bath today. CNA 1 stated Resident 7 did not receive showers because it was difficult and caused Resident 7 pain to position Resident 7 in the shower chair.

During an interview on 6/13/2024 at 10:42 a.m. with CNA 1, CNA 1 stated Resident 7 wore a hospital gown because Resident 7 was usually in bed. CNA 1 stated Resident 7 was dressed in regular clothes when the family came to visit and when Resident 7 was transferred into a special type of chair.

During an interview on 6/13/2024 at 3:42 p.m. with the Director of Nursing (DON), the DON stated Resident 7 did not have any care plans preventing Resident 7 from getting out of the bed.

The DON stated Resident 7 was alert and should not be in bed.

The DON stated the facility was not maintaining Resident 7's mobility and quality of life while Resident 7 remained in bed.

During a concurrent interview and record review on 6/13/2024 at 5:13 p.m. with the Activity Assistant (AA), AA reviewed Resident 7's activity log from 1/2024 to 6/2024 and stated Resident 7 was seen for activities in the bedroom. AA stated the purpose of the activity program was to assist the residents (in general) with participation, communication, and cognitive function. AA did not know the reason Resident 7 was not assisted out to the activity room and stated, I can't imagine lying in bed all day.

A review of the facility's policy and procedure (P&P) titled, Resident Rights - Quality of Life, revised 2017, indicated each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.

The P&P also indicated resident were encouraged and assisted to dress in their own clothes rather than in hospital gowns.

555117

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555117 B.

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

During a concurrent observation and interview with Certified Nursing Assistant (CNA) 4, on 6/13/2024, at 2:47 a.m., inside Resident 64's room, CNA 4 confirmed Resident 64's bed had bed rails on both sides of the bed.

During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 4, on 6/13/2024, at 4:33 p.m., Resident 64's MDS, dated [DATE], was reviewed and indicated Resident 64 was not using bed rails. LVN 4 stated Resident 64 had side rails on both sides of the resident's bed. LVN 4 stated the MDS should indicate that Resident 64 used bed rails daily. LVN 4 further stated assessments should always match what is ongoing and the care provided to the resident because residents can be potentially provided the wrong interventions with an inaccurate assessment.

During an interview with the Director of Nursing (DON), on 6/13/2024, at 6:14 p.m., the DON stated it is important to have an accurate assessment in the MDS for bed rail use because assessments promote care to be used for bed rails.

A review of the facility's policy and procedure (P&P) titled, RAI [Resident Assessment Instrument] Process, last reviewed 4/4/2024, indicated the purpose was to provide resident-assessments that accurately depict and identify resident-specific issues and objectives as required, while meeting state and federal guidelines and data submission requirements.

43988

2. A review of Resident 12's Admission Record indicated the facility admitted the resident on 11/10/2023 with diagnoses including dementia (a general term for the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and hypertension (a condition in which the force of the blood against the artery walls is too high).

A review of Resident 12's History and Physical, dated 11/30/2023, indicated the resident did not have the capacity to understand and make decisions.

During a concurrent interview and record review on 6/12/2024 at 4:10 p.m. with MDS Coordinator (MDSC), reviewed Resident 12's Order Summary Report dated 11/10/2023 and MDS Assessment, dated 2/22/2024. MDSC verified Resident 12 had physician's order for admission under Hospice Provider 1 (HP 1) on 11/10/2023.

The MDSC verified Resident 12's MDS Assessment should have reflected Resident 12 was receiving hospice services while a resident in the facility.

The MDSC stated not having an accurate MDS assessment can result in staff not being aware of the resident's plan of care which can lead to a delay in providing the resident hospice care and services.

A review of the facility's policy and procedure titled, RAI Assessment, last reviewed 4/4/2024, indicated the following:

555117

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555117 B.

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

During an observation on 6/11/24 at 9:09 AM, in medication cart 1, Licensed Vocational Nurse (LVN) 1 was observed crushing Metoprolol Succinate ER 50 milligram ([mg]-a unit of measure of mass) tablet and adding them to a small cup filled with water and opening Duloxetine DR 30 mg capsule and pouring the contents to another small cup filled with water, for Resident 295.

According to the manufacturer package insert (a document that provides information about the medication,) dated 3/2006 for Metoprolol succinate ER tablets, the document indicates that Metoprolol succinate ER tablets should not chewed or crushed.

According to the manufacturer medication guide (a document approved by the Food and Drug Administration [FDA - agency responsible for protecting the public health by ensuring the safety, efficacy, and security of human drugs] that gives information to patients about medications to avoid adverse effects,) dated 8/2023 for Duloxetine DR capsules, the document indicates that Duloxetine DR capsules should not be chewed or crushed, to not open the capsule and sprinkle on food or mix with liquids, and opening the capsule may affect how well Duloxetine DR capsules work.

555117

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555117 B.

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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039

During an observation on 6/11/24 at 9:09 AM, in medication cart 1, LVN 1 was observed crushing Metoprolol Succinate ER 50 mg tablet and adding them to a small cup filled with water and opening Duloxetine DR 30 mg capsule and pouring the contents to another small cup filled with water, for Resident 295.

According to the manufacturer package insert (a document that provides information about the medication,) dated 3/2006 for Metoprolol succinate ER tablets, the document indicates that Metoprolol succinate ER tablets should not chewed or crushed.

555117

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 555117 B.

Wing 06/13/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Skyline Healthcare Center - LA 3032 Rowena Ave Los Angeles, CA 90039