Almaden Health and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a person-centered care plan for fall prevention for one of three sampled residents (Resident 1) when one intervention to place a non-slip strips in the shared resident's restroom's floor was not done. This failure could potentially put Resident 1 at risk of falling and could result to injuries. Review of Resident 1's face sheet indicated admission to the facility on 6/9/14, with diagnoses including unspecified dementia (is an umbrella term for a decline in mental abilities-like memory, thinking, and reasoning-that is severe enough to interfere with daily life ) with other behavioral disturbance and muscle weakness (limits your mobility). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sample residents (Resident 1) received medication as ordered, whentwo medications were not available at scheduled time, andOne medication was not administered after it was delivered to the facility. Those failure had the potential to compromise Resident 1's health and well-being. A review of Resident 1's medical record indicated he was admitted to the facility on [DATE] at 11:45 p.m. with diagnoses including unspecified intracranial injury (damage to the brain resulting from external physical force, such as falls, accidents, or assaults ), nontraumatic subarachnoid hemorrhage epilepsy (seizures), and cerebral edema(dangerous, often life-threatening brain swelling caused by fluid buildup from injury, tumors, infection, or stroke ). [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to maintain a safe and functional environment when: 1. The toilet in Resident 9's room was clogged; 2. Resident 9's bathroom call light was broken; and, 3. The facility's three of four shower rooms had multiple broken tiles. These failures compromised residents' safety, well-being, and access to a properly maintained living environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide proper oxygen (a colorless, odorless gas) care and treatment services for four of 18 sampled residents (Residents 168, 60, 268, and 29) when: 1. Resident 168 had an oxygen concentrator (a portable device that provides oxygen) at the bedside, but there was no oxygen signage posted on the door. 2. Resident 60 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. 3. Resident 268 had an oxygen concentrator at bedside, but the nasal cannula had no label, and no oxygen signage posted on the door. 4. Resident 29 had an oxygen concentrator at the bedside, but there was no oxygen signage posted on the door. This deficient practice had the potential to for accidents and hazards that could pose harm to residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage practices and sanitary conditions in the kitchen when: 1. Kitchen staff did not wear hair restraints while in the kitchen, 2. Five of seven green peppers were wrinkled and soft, one of 3 cucumbers soft, 3. Three opened spice containers and one vanilla extract bottle with expired dates, 4. Three of eight cutting boards had deep cut marks on their surface, and 5. Two of 18 cans of sliced peaches, one of 12 cans of sliced pears, one of 6 cans of fruit cocktail were dented, and one of three cans of nacho cheese sauce with expired date of 12/23/24, in the emergency food supplies. These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. One Licensed Vocational Nurse (LVN) A failed to use the proper disinfectant (chemical liquid that destroys bacteria) to disinfect a shared (used for multiple residents) glucometer (blood glucose meter to measure and display the amount of sugar [glucose] in the blood) according to manufacturer's instructions and accepted professional standards for one resident; 2. One housekeeping staff failed to handle and transport dirty laundry properly; and 3. The facility staff failed to ensure proper storage of Resident 64's breathing treatment (nebulizer treatment, which involves inhaling a mist of medication through a device) mask. These failures could result in cross-contamination and the spread of infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of cockroaches and spiders when: 1. Roach and spider carcasses were observed in the kitchen, 2. No monitor log for deep cleaning of resident rooms reported to have sighting of roaches, and 3. Facility did not follow their facility's plan of correction regarding pest control. These failures had the potential to cause health hazards and food borne illness to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dignity and privacy to one of 18 sampled residents (Resident 52) during care when Resident 52's lower back was partially exposed to public view while seated in a shower chair in the facility's hallway. This failure compromised Resident 52's dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident's care needs were accommodated for one of six sampled residents (Resident 37) when Resident 37's call light /button (a button device used to request assistance) was not within reach to use. This failure had the potential to affect the resident's ability to request for prompt assistance and help.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and meet current standards of nursing practice when, the medication was not administered according to the physician's order for one of 10 residents (Resident 65). This failure could potentially result in complications of the residents' medical conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a sanitary environment was provided when: 1. The dumpster's lid for garbage was not fully closed and 2. Leftover foods and some trashes were found on the ground of facility's garbage storage area. These failures had the potential to attract rodents and pests and may put residents' health and safety at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe environment when the screen that covers the window leading to the kitchen sink was broken. This failure had the potential for the rodents and pests to enter the kitchen and had the potential to put residents' health and safety at risk.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to implement infection control practices when: 1. Licensed vocational nurse B (LVN B) walked in the hallway with gloves on; 2. Housekeeper C (HKP C) wore the same gloves to wipe resident Room AA and Room BB; and 3. Certified nursing assistant D (CNA D) brought the lunch tray to Resident 2's room which was an isolation room for Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus which can spread from an infected person's mouth or nose in small liquid particles when they cough, sneeze, speak, sing or breathe) and fed her in the room wearing a surgical mask. These failures had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain an effective pest control to keep the facility free of cockroaches when live cockroaches were observed in Resident 4's room even though the room was inspected and treated for roaches. This failure had the potential to result in pest transferred disease to residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to treat one of three sampled residents (Resident 1) with respect and dignity when certified nursing assistant A (CNA A) did not provide privacy to Resident 1 during transporting Resident 1 from her room to the shower room. This failure had the potential to cause embarrassment for the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for four of 18 sampled residents (Residents 35, 37, 23, and 172) when: 1. For Resident 35, the facility failed to change the wound dressing as ordered and failed to label the wound dressing with the initial, date, and time; 2. For Resident 37, medication was left unattended in the room; 3. Creatinine with estimated glomerular filtration rate (creatinine with eGFR, a test that measures the level of kidney function and determines the stage of kidney disease) test was not done for Resident 23 as ordered; and 4. The wound care nurse (WCN) did not provide treatment to Resident 172's sacrum wound as ordered by the physician. These failures had the potential to negatively affect the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had an environment free from accident hazards when red sharps (objects with sharp points or edges such as needles or syringes) containers were left open, unattended, and accessible on two out of three medication carts. This failure had the potential to put residents and staff at risk for injuries from needlesticks and sharp objects.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored and distributed and the kitchen floor was maintained in accordance with professional standards for food service safety when: 1. The resident food refrigerator was found out of the safe temperature range; 2. Multiple resident meal trays had crack, rough edges; 3. The floor below the dish machine had two broken tiles; and 4. The ice machines had rough whitish build up on parts. These failures had the potential to cause the growth of microorganisms or attract pests which could cause foodborne illness or cross contaminate food or ice (cross contamination occurs when unclean surfaces or utensils spread germs to food and could potentially cause foodborne illness) for the 68 residents eating at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices when: 1. Resident 17's suction tubing and canister were undated; 2. The wound care nurse (WCN) placed Resident 172's urine bag on his bed and let it touching the floor, opened Resident 172's night stand with contaminated gloved hand, and asked certified nursing assistant L (CNA L) to hold the clean dressing on Resident 172's left heel wound with her contaminated gloved hand; 3. Speech therapist (ST) did not practice standard precautions; 4. CNA did not use proper personal protective equipment (PPE) for contact precautions; 5. CNA wore PPE in the hallway and disposed of a unsealed trash bag from the contact isolation room on the storage room floor. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive person-centered care plan for three of 18 sampled residents (Resident 61, 7, and 56) when 1. For Resident 61,who could not speak English, the facility failed to develop a care plan to address the communication barriers; 2. For Resident 7, the facility failed to develop a care plan to address the management of seizures; and 3. For Resident 56, the facility failed to develop a care plan to address the management of diabetis mellitus (DM, increase blood sugar) foot. These failures had the potential to result in the residents not receiving the care and services necessary to maintain their health, safety and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide communication services to one of 18 sampled residents (Resident 28) who spoke in their non-English language. This failure had the potential for the resident not to maintain or improve her ability to carry out the activities of daily living (ADL).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary podiatry services for one of 18 sampled residents (Resident 56) when his toenails were long enough to curl under. This failure had the potential to affect the resident's foot health and contribute to injury and/or infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dialysis services consistent with professional standards for one of three residents (22) who received hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte, i.e. salts and mineral imbalances by using a machine and an artificial kidney) when staff and Resident 22's clinical record indicated the wrong dialysis access site; and Resident 22's dialysis communication records were missing. These failures had the potential for the resident to be inaccurately assessed and be at risk for complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) with the resident or resident representative (RR, a person empowered to make decisions for the resident/person legally responsible and liable for a decision or an action) and obtain the physician's order and informed consent prior to the use of bed rails for one of 18 sampled residents (Resident 7). This failure had the potential to put the resident at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement procedures to ensure safe handling of hazardous drugs (medications capable of causing serious effects); and ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: 1. Hazardous drug handling procedures were not implemented during medication pass observation for Resident 274; 2. Random controlled medication use audit for two of six sampled residents (Residents 12 and 322) did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. [...]

Inspectors wroteBased on interview, and record review, the facility failed to request a medication regimen review (MRR) following changes in condition (worsening of an existing problem or the emergence of new signs or symptoms, such as falls or seizures) for two out of five sampled residents (Resident 48 and 59); and failed to ensure the consultant pharmacist (CP) identified potential medications contributing to falls and make recommendations to the facility for reduction or discontinuation of one of the medications during the monthly MMRs for Resident 59. This failure had the potential for medications not being optimized for best possible health outcome, and unnecessary or prolonged use of medications which could lead to medication adverse effects (such as falls) for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 18 sampled residents (Resident 33) was free from unnecessary medications when the nursing staff did not monitor for signs and symptoms of adverse effects related to the use of blood thinning medications. Resident 33 was receiving Xarelto (generic name rivaroxaban, an anti-coagulant, or blood thinning medication). This failure had the potential for side effects of this medication (such as bleeding, excessive bruising, etc.) to go undetected or recognized for timely intervention.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 34 opportunities during the medication pass resulted in two errors. The calculated medication error rate was 5.88 percent. These failures placed Residents 38 and 274 at risk for not receiving the full therapeutic effects of medications when medications were not given according to the manufacturer's specifications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications in two of two medication carts inspected when: 1. Medication Cart 3 contained two (2) expired medications and one (1) test strip (thin plastic strips which measures blood sugar levels) vial opened without an open date label; 2. Medication Cart 1 contained one (1) expired medication and one (1) test strip vial opened without an open date label. The deficient practices had a potential for residents to receive unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and not being removed from active stock.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of six residents (Resident 51) received pneumococcal vaccinations based on the facility's policy. This failure had the potential to expose the resident to pneumococcal infections (caused by common bacteria [streptococcus pneumonia] that can affect different parts of the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services, when: 1. There was ice-build up on the ceiling in the walk-in freezer. 2. There was no adequate amount of sanitizing solution (quat) in one of the red bucket containers. 3. The wall fan had black matter on the blades and front grill. 4. One dietary staff was not properly wearing a hair restraint. These failures had the potential to result in food borne illness among residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide safe and homelike environment for five of 18 residents when, (1) The armrests of Resident 2's wheelchair and Resident 45's bed bolster (long pillow or cushion used to suppport the body part of persons lying on bed) were ripped, and (2) Residents 39, 63 and 221's bed privacy curtains had brown stains. These failures had the potential to result for psychosocial harm should residents experience decreased sense of well-being.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plan (a document which provides direction for and communicates to staff the individualized care of the resident) for two of 18 sampled residents (Residents 4 and 56) when: Residents 4 and 56's fall care plans were not revised to include interdisciplinary team (IDT) recommendations made to prevent further falls. This failure had the potential to result in the repeat occurrence of falls for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to change the midline catheter (put into a vein by the bend in elbow or upper arm) dressing for one of two residents (Resident 18). This failure had the potential to result to intravenous (into a vein) complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately provide activities for two of five sampled residents (Residents 8 and 61) to support their physical, mental, and psychosocial well-being when activities for Residents 8 and 61 were limited in number and not following the care plans. 1. Resident 8 was admitted with diagnoses which included muscle weakness, dementia, and altered mental status. Multiple observations during the survey, Resident was observed in bed. During an interview with the activities director (AD) on 1/23/2020 at 3:19 p.m., she stated she played music for Resident 8 from her phone for five minutes, which is about two songs. The AD stated she also him pictures from a showed calendar, did reality orientation (the day, month, year from the calendar), and sometimes aroma therapy with unscented lotion. [...]