Castle Manor Nursing & Rehabilitation Center

kept private for one of 4 sampled residents (181) when Licensed Nurse (LN) 11 left Resident 181's

unattended.

As a result, Resident 181's right to privacy and confidentiality was violated.

Findings

Resident 181 was admitted to the facility on [DATE] with diagnoses which included fracture (complete or partial brake in a bone) of superior rim of right pubis (upper edge of right pubic bone) per the facility's admission Record.

On 3/26/25 at 10:32 A.M., an observation of LN 11, during medication administration in room [ROOM NUMBER] A was conducted. LN 11 left three (3) bubble wrap medications of resident 181 over a medication cart, outside room [ROOM NUMBER] A, unattended.

The bubble wrap medications contained residents name, medication's name and dosage (Lexapro 5 mg one tab daily- a medication for depression, Losartan 25 mg one tab daily- a medication for blood pressure control, Namenda 10 mg one tab twice a day- a medication for dementia[decline in mental ability] ) .

On 3/26/25 at 10:45 A.M., an interview with LN 11 was conducted. LN 11 stated he should have not left resident 181's bubble wrap medications over the cart, exposed to the general public, unattended.

LN 11 acknowledged it was a privacy and HIPAA (Health Insurance Portability and Accountability Act,- a federal law that sets national standards for protecting sensitive patient health information) issue.

On 3/27/25 at 8:55 A.M., an interview with Charge Nurse (CN) 11 was conducted. CN 11 stated residents bubble wrap medications should have been placed inside the locked medication cart. CN 11 further stated leaving a resident's bubble wrap medications unattended was a privacy and HIPAA issue.

On 3/27/25 at 1:10 P.M., an interview with the Director of Nursing (DON) was conducted.

The DON stated Resident 181's bubble wrap medications should have not been left unattended over the cart.

The DON stated resident's bubble wrap medications contained resident's name and medication.

The DON stated the expectation was for LN 11 to put resident 181's bubble wrap medications inside the locked cart before going in to Resident 181's room.

The DON stated it violated Resident 181's privacy and confidentiality.

Per the facility's policy titled, Confidentiality of Information and Personal Privacy, revised October 2017, indicated, .

Policy Interpretation and Implementation .1.

The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .

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Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

According to the admission Record, Resident 41 was admitted on [DATE] and readmitted on [DATE] with diagnoses which included need for assistance with personal care.

A review of the Minimum Data Set (MDS-an assessment tool) indicated Resident 41 had a BIMS (a score to measure cognition) of 15, indicating Resident 41 was cognitively(thinking processes) intact.

On 03/24/25 at 8:30 A.M., an observation and interview was conducted with Resident 41. Resident 41 stated he was diagnosed with scabies (a rash caused by a tiny mite which causes intense itching) in January 2025. Resident 41 lifted up his shirt and multiple red bumps were observed on his shoulders,chest, and stomach. Resident 41 stated, .These [rashes] overrun me .they're eating me up .they gave me scabies .they're hearty little suckers! Resident 41 stated although he had been treated for scabies, he is still experiencing intense itching.

On 3/26/25 at 2:08 P.M., a joint interview and record review was conducted with the Treatment Nurse (TN).

The TN stated he was aware that Resident 41 had been treated for scabies, but did not know that Resident 41 still had an itchy rash.

The TN stated there was no written care plan for Resident 41 that addressed the rash.

The TN stated it was important to have a care plan to see what can be done to treat Resident 41, and to reassess to see if the plan was effective.

The TN stated, .We also need to update it as needed. If the original plan isn't working, if he is still itching, we should have updated it to help the resident .

On 3/27/25 at 9:48 A.M., an interview was conducted with the Director of Nursing (DON).

The DON stated Resident 41 should have had a care plan to address his itchy rashes, even after he was already treated for scabies.

The DON stated, We should have started a care plan when [the scabies] was first diagnosed and updated [the care plan] as it progressed to see if the interventions were working or not working .

A review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revised March 2022 indicated, A comprehensive, person-centered care plan that includes measureable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

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Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

She stated resident was up in her wheelchair when she started her shift at 7:30 A.M. CNA 11 stated

.she is would get a bedsore if she stays up for a long time .

On 3/27/25 at 9:08 A.M. an interview was conducted with the Director of Nursing (DON).

The DON stated, The resident should be repositioned, even if she's in the wheelchair. We are trying to prevent the reopening of wounds. We also want to prevent any new wounds .

A review of the facility's policy titled Repositioning revised May 2013 indicated, Interventions .3.

Residents who are in bed should be on at least an every-two-hour (q2 hour) repositioning schedule .5.

Residents who are in a chair should be on an every-one-hour (q1 hour) repositioning schedule .

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Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

observed Resident 41 smoking a lit cigarette in his room. LN 14 stated, I called the Social Services

.we should have done an IDT. It wasn't safe. He can hurt himself and others .

A review of Resident 41's Progress Notes dated 12/26/24 indicated, SSA was told that resident is smoking in his room. SSA and charge nurse went to patient [sic] room, and he is till [sic] smoking his cigarette. SSA asked for his cigarette, and he handed it over and he stated that he thought that he is outside smoking. SSA told him that he cannot smoke at all inside the facility only at the designated areas and he is verbalizing of understanding. SSA took his cigarette and his lighter and made him aware that if he needs to smoke to ask the charge nurse so that he can be accompanied at the smoking area, and he is verbalizing of understanding .

A review of Resident 41's Electronic Health Record (EHR) indicated Resident 41 had a Smoking Risk assessment completed on 1/15/25.

There was no record that a Smoking Risk Assessment was completed when Resident 41 was admitted on [DATE], and when readmitted on [DATE]. A review of Resident 41's EHR indicated there was no IDT note done when Resident 41 was found smoking a cigarette inside the facility.

On 3/27/25 at 9:48 A.M., an interview was conducted with the Director of Nursing (DON).

The DON stated, .We should have addressed the smoking, make sure we documented what we did about it.

The IDT should have been notified .to keep [Resident 41] and other patients safe .

A review of the facility's undated policy titled Smoking Policy indicated, .Smoking is only permitted in designated resident smoking areas .Smoking is not allowed inside the facility under any circumstances .Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes .d. ability to smoke safely with or without supervision .13.

Resident smoking material(s) will be secured and stored at the nursing station .

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Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

readmitted on [DATE] with diagnoses which included Type 2 Diabetes (a condition that affects how

score to measure cognition) of 15, indicating Resident 41 was cognitively intact.

On 3/26/25 at 2:07 P.M., during an interview with Resident 41, a plastic medicine cup with a yellow capsule was observed on Resident 41's bedside table. Resident 41 stated, .The nurse brought it here and put it on my table. I just forgot to take it earlier .

On 3/26/25 at 2:10 P.M. an interview was conducted with Licensed Nurse (LN) 5. LN 5 stated she brought the capsule in at 1 P.M. but she turned her back and did not see Resident 41 take the medication. LN 5 stated, .I should have made sure that he swallowed it, to make sure that he took it .to make sure he got the proper dose of the medication.

Also, [the bedside table] is really close to his door so we don't want anyone else to take it .it's not safe to leave a medication there . LN 5 stated since the medication was due at 1 P.M., it was now being given late.

On 3/27/25 at 9:48 A.M. an interview was conducted with the Director of Nursing (DON).

The DON stated, .Medications should never be left with the resident because you can't ensure residents took it .

The DON stated it was important that the nurses make sure the medication is taken before leaving the resident because there was a chance another resident could come in and take it.

A review of the facility's policy titled Administering Medications, dated 2001, indicated, .Medications are administered in a safe and timely manner, and as prescribed .

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Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

high risk, high volume, and/or problem prone .

Program-Feedback, Data, and Monitoring, dated March 2020, indicated .2.

The QAPI process focuses

outcomes related to resident care, quality of life, resident safety, resident choice or resident autonomy, and on making good faith effort to correct or mitigate these outcomes .

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Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

privacy curtains and before touching Resident 34's G- tube. LN 11 stated hand hygiene was important

On 3/27/25 at 8:52 A.M., an interview with Charge Nurse (CN) 11 was conducted. CN 11 stated LN 11 should have performed hand hygiene and put on a new pair of gloves while providing care and in between touching Resident 34's belongings and privacy curtain to prevent cross-contamination and the spread of infection.

On 3/27/25 at 9:12 A.M., an interview with Infection Preventionist (IP) was conducted.

The IP acknowledged LN 11 should have performed hand hygiene and put on a new pair of gloves after touching Resident 34's environment but did not.

The IP further stated this should have been done to prevent cross-contamination.

On 3/27/25 at 1:10 P.M., an interview with the Director of Nursing (DON) was conducted.

The DON stated the expectation was for LN 11 to perform hand hygiene and changed his gloves in between touching Resident 34's environment and providing care to prevent cross-contamination.

Per the facility's policy titled, Handwashing/Hand Hygiene, revised October 2023, indicated, Policy .Indications for Hand Hygiene .1. d. after touching a resident; e. after touching the residents' s environment .

During the recertification survey, deficient trends in Advanced Directives were identified by surveyors.

The ADM stated that this trend had not been identified by the QAA Committee and/or included in the QAPI plan.

On 3/27/25 at 2:30 P.M., an interview with the ADM was conducted.

The ADM stated that the expectation was the QAA Committee should have identified the deficient trend with advanced directives that was identified by the surveyors during recertification survey. In addition, the ADM stated the deficient trend should have been included in the QAPI plan.

The ADM stated the importance of QAA Committee identifying deficient trends and including them in the QAPI plan was to promote the highest standard of care for their residents.

Review of facility policy titled Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership dated March 2020, indicated .4.

The responsibilities of the QAPI committee are to: .b.

Identify, evaluate, monitor, and improve facility systems and processes that support delivery of care and services; c.

Identify and help to resolve negative outcomes and/or care quality problems identified during the QAPI process .

Review of facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, indicated .Implementation .The QAPI plan describes the process for identifying and correcting quality deficiencies.

Key components include .c.

Identifying and prioritizing quality deficiencies .

Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Analysis and Action, dated March 2020, indicated .1.

The QAPI program, overseen by the QAPI committee is designed to identify and address quality deficiencies through the analysis of the underlying cause and actions targeted at correcting systems at a comprehensive level .

555263

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 555263 B.

Wing 03/27/2025

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

Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950

Review of Resident 12's (R12) Admission Record dated 3/26/25 indicated R12 was admitted for diagnoses which included: Acute Respiratory Failure(a life-threatening condition where the lungs are unable to adequately exchange oxygen and carbon dioxide), Asthma(a chronic lung disease), Congestive Heart Failure(a chronic condition where the heart muscle is weakened and cannot pump blood effectively), Myocardial Infarction( another term for heart attack)and Pneumonia(an infection of the lungs).

Review of R12's physician orders dated 3/26/25 indicated .Resident is (Capable) Of Understanding Rights, And Informed Consent.

Review of R12's Minimum Data Set (MDS-standardized assessment tool used in Medicare and Medicaid certified nursing homes) Section C, dated 3/2/25, indicated that R12's Brief Interview for Mental Status (BIMs-a screening tool used to assess memory and orientation in nursing homes) was scored 15 which indicated intact cognition (thinking processes).

Review of R12's Care Plan Report dated 3/26/25 indicated, .Resident has the right to .formulate an advance directive .Offer the opportunity for resident .to review/complete POLST (Physician Orders for Life-Sustaining Treatment-It is a medical document that outlines a patient's wishes regarding end-of-life care) form with Physician/Nurse Practitioner as needed .

On 3/24/25 at 8:30 A.M., a record review of the electronic medical record (EMR-computer based charting) was conducted for R12. No advanced directive or POLST were in the EMR.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

555263

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 555263 B.

Wing 03/27/2025

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

Castle Manor Nursing & Rehabilitation Center 541 V Avenue National City, CA 91950