Peninsula Post-Acute

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff assessed and reported significant changes in condition for 1 of 1 resident (Resident 1) who experienced two documented episodes of tachycardia (fast heart rate). This failure had the potential to place the resident at risk for delayed recognition and treatment of an acute medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when the kitchen did not document the initial temperatures for 3 food items on the cool down log. These failures were likely to result in putting residents at risk for foodborne illness (diseases caused by consuming contaminated food or drink). Cooling is the specific method and guideline used to rapidly lower the temperature of cooked food to a safe storage level, preventing bacterial growth. Improper cooling is a major factor in causing foodborne illness. Taking too long to chill potentially hazardous food, which means food that requires time/temperature control for safety to limit the growth of pathogens, has been consistently identified as one factor contributing to foodborne illness. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a food storage area was pest free when rodent droppings were seen in a dry good storage area. This failure may expose residents to contaminated food items and/or expose residents to food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to investigate an unusual occurrence for Resident 69, 1 out of 15 sample residents. Resident 69 had a fall and had neurosurgery (surgery to the brain) ten days later. Failure to investigate an unusual occurrence for Resident 69 did not ensure the facility had ruled out neglect and/or potential failures within their system for provision of nursing care.

Inspectors wroteBased on interviews and record reviews, the facility failed to update a comprehensive, person-centered care plan for one of 15 sampled residents (Resident 18) when facility staff continued to maintain Resident 18's urinary catheter care plan after the urinary catheter had been discontinued. This failure had the potential to result in care that did not reflect Resident 18's current needs and failed to support his highest practicable well-being. Review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including obstructive and reflux uropathy (a condition when urine flows backward from the bladder up to the kidneys) and benign prostatic hyperplasia (BPH, a noncancerous enlargement of the prostate gland) with lower urinary tract symptoms. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to meet professional standards of quality when one of two sampled resident (Resident 18) received oxygen therapy outside the prescriber's order. This failure could potentially result in unnecessary treatment, and care that was not clinically indicated for Resident 18. Review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that makes breathing hard), acute and chronic respiratory failure with hypoxia (low oxygen in the body), and syncope (passing out) and collapse. Review of Resident 18's oxygen care plan, initiated on 3/4/26, indicated interventions to change humidification and oxygen tubing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate administration of medication when nursing staff did not follow the prescribed medication order for one of three sampled residents (Resident 52). This failure resulted in prescribed dose not being administered and may not manage Resident 52's pain. Review of Resident 52's Physician Order, dated 3/3/26, indicated lidocaine (used for pain relief) 4% patch was to be applied to the lower back for pain. The order specified applying two patches to clean, dry skin at 9:00 AM, to be worn for 12 hours and removed at 9:00 PM.During a concurrent medication pass observation and interview on 3/25/26 at 9:41 AM, an unlabeled patch was observed on Resident 52's back. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications (drug or medicine, used to diagnose, cure, treat, or prevent disease) and biologicals were properly stored when one of one sampled medication storage room refrigerators contained an opened and undated multi dose vial (a small bottle of medication that contains more than one dose) for Resident 41. This failure had the potential to result in the use of unsafe and expired medication for Resident 41. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment when: 1. The fish served was not cooked to the appropriate temperature; 2. The fish was not thawed properly; 3. The resident's refrigerator contained unlabeled, undated and expired items; 4. Proper hand hygiene and glove use was not followed; 5. The microwave was not clean; 6. The plate warmer was not clean; and 7. The food carts were not cleaned appropriately; These failures had the potential to result in contamination of food, food preparation equipment, and utensils used for food, leading to food borne illness (any illness resulting from eating contaminated/spoiled foods) for 56 residents who received food from the kitchen. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent (5%) when 10 medication errors occurred out of 40 opportunities during the medication administration for four residents (Resident 53, Resident 43, Resident 219, and Resident 24, resulting in an error rate of 25%. 1. Licensed Vocational Nurse (LVN) 3 did not observe Resident 53 take her medications after leaving seven (7) of the prescribed medications on the bedside table. 2. Registered Nurse (RN) 1 administered Resident 43's Repaglinide (used to treat type 2 diabetes mellitus [high blood sugar]) during meals. 3. Insulin was not administered according to professional standard of practice for Resident 219 and Resident 24. In addition, insulin was administered without a prescribed blood sugar check for Resident 24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled and stored according to manufacturer's instruction and facility policy and procedure; expired biologicals were removed from the active storage area; and medication cart was locked when left unattended. These deficient practices had the potential to compromise the integrity and effectiveness of the drugs and biologicals; and may jeopardize the health and safety of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were plated in accordance with the approved menu when the incorrect scoop size was used for serving green beans to residents for a lunch meal. This failure to follow the planned menu had the potential to result in residents' diets not being given in accordance with the prescriber's order and diet specifications, resulting in residents not receiving the amount of nutrients to meet their nutritional needs to 49 residents who received regular textured green beans according to the menu and the lunch tray tickets.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide palatable food for a lunch meal including: 1. Meatballs; and 2. Pureed green beans. The failure to provide palatable food had the potential to reduce residents' food and nutrient intake leading to weight loss and/or nutritional medical complications for 34 residents who received meatballs or pureed green beans according to diet orders on the lunch meal tickets out of 56 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to furnish a completed written agreement for dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) services or transportation to dialysis that was being provided by an agency outside the facility. This failure has the potential for residents that require dialysis to not have services held to a standard agreed upon by the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Physician Orders for Life-Sustaining Treatment (POLST, a written medical order that specifies the types of medical treatment a patient wants to receive in the event of a serious illness) was obtained on admission for one of 18 sampled residents (Resident 219). This failure had the potential to result in resident's wishes in an emergency situation and end-of-life choices not being honored.

Inspectors wroteBased on interview and record review, the facility failed to accurately encode one of 18 sampled residents' (Resident 20) Minimum Data Set (MDS - a federally mandated resident assessment tool) when Resident 20 was encoded has being diagnosed with Depression, but the Resident had no current or past medical history of that diagnosis. This failure has the potential to result in MDS assessments that inaccurately captures quality metrics and a resident's condition over time.

Inspectors wroteBased on interview and record review, the facility failed to develop an accurate comprehensive care for two of 18 sampled residents (Resident 20 and Resident 31) when: 1. Resident 20's care plan for Duloxetine (an anti-depressant medication that can also be used to treat nerve pain) had the incorrect indication (reason to give a medication) 2. Resident 31's care plan for indefinite use of Cephalexin (an antibiotic) was not developed. These failures have the potential for residents' care plans to not be person-centered and specific enough for residents to meet their medical and physical needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and treatment according to facility policies and procedures and professional standards of practice for two of 18 sampled residents (Resident 291 and Resident 24) when: 1. Insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) injection was not prepared and administered according to current professional standard of practice and facility's insulin administration policy and procedure for Resident 219 and Resident 24. 2. Glucose (blood sugar) reading for Resident 24 was obtained during meals. Additionally, insulin was administered without a prescribed glucose check for Resident 24. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of 18 sampled residents (Resident 26) had the necessary language systems for translation accessible when Resident 26 requested a translator but multiple staff were not aware of resources except for family or the use of a communication board (a tool that helps people with limited language skills express themselves by pointing to images or symbols). This failure has the potential for staff to not properly assess residents who speak a different language or make it difficult for a resident to make their unique needs known.

Inspectors wroteBased on interview and record review, the facility failed to monitor for behavioral symptoms, side effects and/or adverse consequences for one of 3 sampled residents (Resident 220) on psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications. Additionally, the informed consent for the use of psychotropic medication was signed seven days after Resident was admitted to the facility. This failure had the potential to place residents on psychotropic medications at risk for adverse health consequences which could negatively impact the resident's mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of 18 sampled Residents (Resident 269) was free of significant medication errors when Resident 269 was given Acetaminophen (a pain medication) beyond the parameters ordered by the medical provider. This failure has the potential to lead to Acetaminophen adverse effects (undesired effect of a drug) including abdominal pain, nausea/vomiting, or liver damage.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure one kitchen staff competency for manual warewashing (warewashing: cleaning and sanitizing of utensils and food-contact surfaces of equipment) using the three-compartment sink. The failure to ensure staff competency for 1 of 8 kitchen staff regarding manual warewashing had the potential to result in contamination of food and/or utensils and equipment leading to illness caused by pathogens (harmful organisms).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's electronic medical record was designed to provide physicians with diet order selections, for residents with renal (kidney) insufficiency/failure, that was consistent with current standards of practice and terminology used by the approved diet manual of the Food and Nutrition Services Department. This failure had the potential for 3 residents (Resident 34, 43, and 54), out of a facility census of 56, who were prescribed a Renal diet (a diet aimed at keeping levels of fluids, electrolytes, and mineral balanced in the body in individuals with chronic kidney disease or who are on dialysis) to receive inappropriate nutrient levels for their individual medical status.

Inspectors wroteBased on interview and record review, the facility failed to operate and provide services to residents of 62 beds when the facility exceeded that capacity and reached 63-64 beds for 13 days in September, 2024. The facility failed to provide services to 62 residents when they admitted 63-64 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control standards for one of 18 sampled residents (Resident 19) when Physical Therapist (PT) 1 and Occupational Therapist (OT) 1 were observed providing care without the necessary personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) used for a resident on enhanced barrier precaution (EBP, an approach where PPE is used during high contact resident care activities to reduce spread of drug-resistant organisms). This failure has the potential to spread infection in the facility or cause infection to a resident that is at higher risk for acquiring an infection.

Inspectors wroteBased on interview and record review, the facility failed to respond in a timely manner to a request for medical records for Resident 1, 1 of 1 sample resident. Failure to provide requested medical records in a timely manner violated Resident 1's right to access her medical records. Additionally, the facility's policy of subjecting residents to a wait of 30-60 days before providing a copy of their medical records does not meet the regulatory definition of timely provision of medical records upon request.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a Registered Nurse (RN) completed an assessment to 4 of 4 sampled residents (Resident 1, 2, 3, and 4) when the residents had a change in condition. The deficient practice had the potential for harm on the resident's safety and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent an injury to one of one sampled resident (Resident 1) when Resident 1 hit her head during the transfer from the wheelchair to the bed. The facility failure resulted to resident to experience severe pain and sustain a bump on the back of her head.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of 13 sampled residents (Residents 53 and 168) were free from neglect when: 1 . Resident 53 reported a staff was rude and failed to help him change out of his wet adult brief. As a result, Resident 53 still have ongoing unpleasant memory of this event and is fearful of working with this staff. 2. Resident 168's family requested pain medication from a nurse. This request was ignored for almost an hour while the Resident was in severe pain. As a result, Resident 168 continued to have severe pain for an hour.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the hospital menu met the nutritional needs in accordance with the Medical Director (MD) approved diet manual, physician ordered diets and current standards of practice. This failure resulted in diets not given in accordance with the prescriber's order and diet specification which may result in resident's not receiving food to meet their nutritional needs and/or receiving food that may worsen their clinical conditions. The lack of comprehensive nutritional analysis, in general, affected 47 residents who were receiving meals from the kitchen. Additionally, of the 47 Residents receiving meals there were 19 Residents with physician ordered carbohydrate consistent diets and eight Residents with chopped diets who did not receive meals in accordance with standards of practice. [...]

Inspectors wroteBased on food production observations, dietary staff interview and dietary document review the facility failed to ensure food was stored and/or prepared in a sanitary manner when there were 1) lapses in infection control, 2) lack of comprehensive cooldown monitoring of potentially hazardous foods prepared from ingredients at room temperature; 3) improper washing/sanitation of food service equipment; 4) ineffective sanitizer strength; and 5) storage of unlabeled and/or undated items. This failure had the potential to put residents at risk for foodborne illnesses (any illness resulting from the consumption of foods contaminated by bacteria, viruses, or parasites).

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure staff upheld a resident's right to be treated with dignity for three of 13 sampled residents (Residents 53, 168, and 24) when: 1. Staff did not answer Resident 53's request for assistance in a timely manner and when staff did not assist Resident 53 with incontinence care. (Refer to F600) 2. Staff did not provide pain management intervention(s) to Resident 168 in a timely manner when requested by a family member and staff did not provide incontinence care in a timely manner. (refer to F600) 3. Staff did not to assist Resident 24 with incontinent care in a timely manner. Failing to treat each residents with dignity had the potential to make them feel unwanted, depressed, and not respected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and homelike environment when the Communal Shower Room (CSR) 2 had peeled and torn non-skid strips. This failure posed a safety risk that may result in injuries to the residents and staff.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure effective Registered Dietitian (RD) oversight of food services when there were lapses in safe food handling standards of practice, and independent evaluation of food service operations. Lack of a Registered Dietitian's oversight may result in 1. consumption of contaminated food, 2. provision of inadequate nutrition to residents, 3. Provision of incorrect food texture or 4. an increase in food related illnesses (Cross Reference F800, F812 and F880).

Inspectors wroteBased on observations, interview and record review the facility failed to ensure meals were plated in accordance with the approved menu. This failure can result in diet not given in accordance with the prescriber's order and diet specification which may result in resident not receiving the full therapeutic effect of the resident nutritional need and/ or provision of inadequate nutrition to residents.

Inspectors wroteBased on meal plating observations, speech therapy interview and departmental document review the facility failed to ensure meal production was consistent with standards of practice when residents with orders for a chopped diet were served a regular hamburger that was cut in half. Additionally, the facility lacked specific diet manual guidance on what constitutes a chopped diet. This deficient practice had the potential to negatively impact nutritional intake for residents with limited range of motion of their hands/arms, and residents with chewing and swallowing deficits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Certified Nursing Assistant (CNA) 2 did not perform hand hygiene before putting on and after removing gloves during resident care activities, and did not remove his gown before leaving Resident 28's room, who was under observation for COVID-19 infection; 2. CNA 3 did not perform hand hygiene before putting on and after removal of gloves; and 3. Two kitchen staff did not perform hand hygiene before putting on and after removing gloves. These deficient practices had the potential to spread infection to the residents, staff, and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain patient care equipment in safe operating condition when: 1. Two drawers of infection control cabinet lack wheels and were resting on the floor, and one drawer had a cracked plastic top, which had the potential to contaminate the PPE (personal protective equipment) stored within the drawers and prevents staff from effectively sanitizing the outside of the drawers. 2. The water pressure gauge of the facility dishwashing machine did not exceed 12 PSI that was not within the manufacturer's recommended Pounds per Square Inch (PSI) of 15-25 PSI. This failure may decrease the dishwasher's effectiveness in cleaning dishes, utensils and other kitchen items.

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of neglect for three of 13 sampled residents (Residents 53, 168 , and 24) were reported within the prescribed timeframes, when the alleged incidents on 2/16/22 was reported on 2/18/22 to the required authorities. This failure had put residents at risk for safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policies and procedures for accurate provision of pharmaceutical services when: 1. Licensed staff failed to accurately reconcile metoprolol (a medication to treat blood pressure) for Resident 368, 2. Tramadol (a medication for pain that is regulated) 50mg (milligram) for Resident 60 was not accurately reconciled on control drug count sheet and medication administration record (MAR). These failures had a potential for Resident 368 to experience adverse effects, Resident 60 having unmedicated pain, and controlled substance discrepancy leading to diversion (stealing of medications).

Inspectors wroteBased on interview, and document review, the facility failed to ensure one of 13 sample residents (Resident 74) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Abilify (antipsychotic medication to treat mental health issues) was administered without a specific condition that was diagnosed and documented in the clinical record and without documented behavioral interventions (individualized non - pharmacological approaches). 2. Celexa (a medication used to treat depression, a persistent feeling of sadness and loss of interest) and Abilify were administered as duplicate therapy (multiple medications for same diagnosis) for depression. These failures had the potential for the resident to receive unnecessary medication which increased the risk of preventable side effects and death.

Inspectors wroteBased on observation, interview and record review, the facility failed to label and store drugs in accordance with current professional standards for four of 13 sampled residents (70, 76, 81, and 82) when: 1. Ensure potentially expired medications were not available for use, 2. Properly label resident medications available for use with expiration date when applicable and in accordance with facility policy and procedures (P & P). These failures placed residents 70, 76, 81, and 82 at risk for receiving ineffective or expired medications and had the potential of exposing residents to infections due to cross contamination.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure meals were palatable (refers to the taste and/or flavor of the food, acceptable to the taste) when the pureed entrée for the noon meal lacked flavor and was not like the regular entrée. This deficient practice had the potential to affect resident's appetite which may result in poor dietary intake that could potentially compromise their health and nutritional status.