Almond View Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation guidelines were followed in the kitchen when opened food items were not labeled and dated. This failure increased the risk of residents being served unsafe food, placing them at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain adequate measures of infection control while administering medications. Licensed Nurse (LN) D failed to properly clean or sanitize medical equipment and medication containers for one of two residents sampled (Resident 40) when:1. The blood pressure cuff (medical device placed on the arm to measure blood pressure), was not cleaned nor sanitized prior to nor after it was used on Resident 40.2. The pulse oximeter (medical device clips on finger to measure blood oxygen saturation and heart rate), was not cleaned nor sanitized prior to nor after it was used on Resident 40.3. The Lidocaine Pain Relief Patch (a pain patch) 4% (percent), package was opened prior to administration, taken into Resident 40's room, and set on the resident's bedside table with no barrier. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan for one of three residents (Resident 24) reviewed for activities to include Resident 24's expressed preference for one-on-one walking after identifying Resident 24's activity needs were not met. This failure resulted in Resident 24 remaining socially isolated and feeling lonely, placing Resident 24 at risk for diminished psychosocial well-being and quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure one of three residents reviewed for activities (Resident 24) received an individual activity program that accommodated the residents vision impairment and supported the resident's interest, independence, and psychosocial well-being when the facility failed to identify and implement meaningful individualized activities that promoted social interaction and engagement consistent with the residents preferences and abilities. This failure resulted in Resident 24 remaining socially isolated and feeling lonely, placing Resident 24 at risk for diminished psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to label and store medications in accordance with professional standards for two of four medication carts when:1. Latanoprost Solution 0.005% (percent) (eye drops) container was found in Cart B on the locked dementia unit that was labeled with an expiration date that had already passed.2. An Insulin Lispro Kwikpen - 100 units (multi-dose insulin syringe) that required refrigeration prior to opening was found unopened and unrefrigerated in the medication cart on station one. These failures had the potential to result in residents receiving medications that are inactive and unable to provide effective results for the health conditions the residents are receiving the medications for, placing residents at risk for physical deterioration, emotional distress, and overall diminished quality of life. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure vulnerable demented residents were free from physical abuse and inappropriate sexual behaviors for 12 of 23 sampled residents when:1. Resident 8 was on top of Resident 7 with his genital (male private part) in her mouth.2. Resident 13 was holding Resident 23's hand over his penis and stroking it.3. Resident 11 was using his hand on Resident 14's hand to stroke his penis.4. a. Resident 4 struck Resident 11 in the face. b. Resident 4 grabbed Resident 1's wrist very aggressively. c. Resident 4 pushed Resident 6 to the ground. d. Resident 4 walked up to Resident 18 and pushed her forehead back. e. Resident 19 would not let go of Resident 4 hand then he grabbed Resident 19's arm. f. Resident 4 hit Resident 20 with his fist, on the left side of her forehead. g. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents in the secured dementia unit (unit that is a specialized residential setting for individuals with Alzheimer's (a disease characterized by a progressive decline in mental abilities) or dementia (a progressive state of decline in mental abilities) that uses secured perimeters, such as locked exterior doors or fenced areas, to prevent wandering while maintaining a safe, structured environment) had sufficient and competent nursing staff and were available to provide nursing and related services to meet the residents' needs when:1 Acuity (complexity and intensity rather than just resident numbers) levels for dementia residents and increased resident altercations were not considered when scheduling Certified Nursing Assistants (CNA) staff in the secured dementia unit.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assurance and Performance Improvement (QAPI) program, when the committee did not monitor, evaluate and track outcomes of a performance improvement plan to ensure sustainability to reduce resident to resident altercations in the secure dementia unit (a specialized residential setting for individuals with Alzheimer's (a disease characterized by a progressive decline in mental abilities) or dementia (a progressive state of decline in mental abilities) that uses secured perimeters to prevent wandering while maintaining a safe, structured environment). This resulted in repeated resident to resident altercations, injuries, nonconsensual sexual conduct, fear, and anxiety. Refer to F600 and F725.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the Minimum Data Set (MDS, resident assessment tool) assessment was accurately coded for wandering behavior (the act of moving from place to place with or without a specified course or known direction) for one of three sampled residents (Resident 12) when the Social Services (SS) did not follow required assessment procedures, relied solely on chart review. This failure resulted in inaccurate assessment coding and failure to fully identify the resident's behavioral needs. It had the potential for staff not to be fully informed of the residents' health status to determine the need for further assessment and care interventions.

Inspectors wroteBased on Observation, Interview, and Record Review the facility failed to ensure federal regulations related to the certification qualification requirement of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with resident assessment accuracy, meal distribution accuracy, safe food handling, and sanitation guidelines.

Inspectors wroteBased on interview and review of Resident Council Minutes the facility failed to act promptly to resolve resident grievances in a timely manner and demonstrate their response and rationale for their response. This action had the potential to violate residents' rights.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the facility food was an appetizing temperature and palatable texture when 14 of 21 sampled residents (Residents 17, 9, 51, 70, 16, 36, 85, 72, 80, and five confidential residents), who received food prepared in the facility kitchen were not satisfied with the facility food temperature and texture. This failure had the potential to result in residents not obtaining appropriate nutritive intake, unplanned weight loss, increased health issue complications, and diminished emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide two out of eight sampled residents (Residents 80 and 92) with dignity and respect when: 1. Resident 80's bed was not made every day. 2. Resident 92 stated, facility staff spoke in a manner, that led her to believe, facility staff did not want to provide care to Resident 92 and had overheard staff talking disrespectfully about her just outside of the door. This failure had the potential to impact resident well-being and cause psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents environment was clean, safe, comfortable, and homelike when: A drain in the kitchen was observed to have missing tile with exposed wood. Two tub and shower rooms used by residents were observed to contain excessive brown stains resembling rust on a handrail and on metal baskets used to hold soap and wash cloths. Doors in residents' rooms bathrooms were observed with scrapes, and gouges of exposed wood. One resident's wall next to his bed had multiple scrapes with exposed drywall. These findings had the potential for injuries to residents and an un home like environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) for one out of eight sampled residents (Resident 92) when Resident 92 notified Licensed Nurse (LN) A that facility staff working the night shift provided rough care (too much force, not careful or gentle). This failure had the potential for allegations of abuse to go unrecognized and placed residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to include nail care to one sampled residents comprehensive care plan (Resident 8). Resident 8 was observed to have long dirty fingernails, and was observed eating with his fingers. This deficient practice led to unidentified need for nailcare, and the potential for injury (scratches), and poor hygiene.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain personal hygiene to one sampled resident that was unable to carry out his activities of daily living (Resident 8). Resident 8 was observed to have long dirty fingernails. This deficient practice led to unidentified need for nailcare, and the potential for injury (scratches) and poor hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 3) dignity was honored when Certified Nursing Assistant C (CNA C) provided personal cares with the window covering open which exposed Resident 3 to an outside courtyard accessible to staff and residents. This failure had the potential to negatively affect Resident 3 ' s physical and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of four sampled residents (Resident 1) was free from physical restraints (any manual method, physical or mechanical device that the individual cannot remove easily that restricts movement or normal access to one ' s body) when a staff member (unknown) put two pillows under Resident 1 ' s mattress which tilted the mattress up and prevented him from getting out of bed. This failure had the potential for Resident 1 to be unable to move freely increasing the risk for the decline of physical functioning, injury, and mental harm from being restricted to his bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received assistance devices to prevent accidents for two of four sampled residents (Resident 1 and Resident 2) when: 1. Staff did not ensure that Resident 1 had his call light (a bedside button that directly signals the nursing staff when a resident required assistance) and a urinal (a plastic container that a resident can urinate in while in bed or next to the bed) within reach per his fall prevention care plan. 2. Staff did not ensure that Resident 2 had anti-rollback brakes (a device that attaches to a wheelchair and locks the wheels when a resident stands up, preventing the chair from rolling away from the resident) on her wheelchair per her fall prevention care plan. These failures had the potential to place Resident 1 and Resident 2 at risk for falls and possible injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a care plan for one of three residents (Resident 2) that would prevent altercations with other residents, thus hindering the delivery of individualized dementia care needs. These failures have resulted in multiple resident to resident altercations with injuries and places this resident at high risk of further harm to others and self.

Inspectors wroteBased on observation and interview the facility failed to ensure one of three residents (Resident 1) was free from abuse when another resident (Resident 2) pushed him down. This failure resulted in a rib fracture of Resident 1.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to refer 2 (Resident #40 and Resident #55) of 4 sampled residents reviewed for preadmission screening and resident review (PASARR) when the resident received a new mental illness diagnosis.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure the accuracy of the preadmission screening and resident review (PASARR) level I screening for 1 (Resident #77) of 4 sampled residents reviewed for PASARR.