Arroyo Vista Nursing Center

Inspectors wroteBased on observation, interview and record review, the facility failed to document nursing care in an accurate, concise manner when:1. Wound treatments were not documented for one of two residents (Resident 36); and,2. Skin observations were documented as being performed for one of two residents (Resident 60) with a condom catheter (a non-invasive device for males that looks like a condom, fits over the penis, and has a tube to drain urine into a collection bag), when no condom catheter was present, when reviewed for documentation. These failures had the potential for Resident 36 and Resident 60's clinical record to be incomplete and inaccurate.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was informed of the right to a bed hold when transferred to the hospital. As a result, one (56) of three discharged residents was not informed of the right to a 7 day bed hold.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's plan of care when a condom catheter (a non-invasive device for males that looks like a condom, fits over the penis, and has a tube to drain urine into a collection bag), was not applied for one of two residents (Resident 60), reviewed for plan of care. This failure had the potential for Resident 60 to experience increased pain and a decline in skin integrity.

Inspectors wroteBased on observation, interview, and record review ,the facility failed to ensure safe infection control practices were followed when a urinary catheter bag (a flexible tube inserted in order to drain urine from the bladder into an external collection bag), and its tubing was in contact with the floor for one of two residents (Resident 5) when reviewed for catheter care. This failure had the potential for Resident 5 to sustain a urinary tract infection from bacteria on the floor.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) was treated with dignity/respect when the facility denied Resident 1 re-entry following a return from being out on pass (OOP; also referred to as a day pass; physician ' s order that gives permission for a resident to leave the facility for a specified period of time). This failure had the potential to affect Resident 1 ' s physical and psychosocial well-being related to feeling betrayed and kicked out from his home. (Cross Reference F-553 and F-657)

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 1) was included in his own person-centered planning of care related to Interdisciplinary Team meetings (IDT; head of department staff meet with the resident to discuss care or concerns/issues) after an incident when the facility refused Resident 1 entry back into the facility following an Out on Pass leave (OOP; physician ' s order that allowed the resident to leave the facility; usually for the day; also referred to as a day pass). This failure resulted in Resident 1 not being informed of the facility rules or expectations when leaving on and returning from, being OOP. In addition, this failure had the potential to result in an AMA (against medical advice)-triggered discharge, which had the potential to affect Resident 1 ' s physical and psychosocial well-being. (Cross-reference F-550 and F-657)

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan related to Out on Pass (OOP; also referred to as a day pass; a physician ' s order that allows the resident to leave the facility for an approved time period) was revised for one resident (Resident 1). This failure had the potential for staff and Resident 1 to be confused on the facility ' s rules when leaving on an Out on Pass. (Cross Reference F-550 and F-553)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary conditions were maintained in the kitchen for food storage methods, according to standards of practice and facility policy when: 1. Multiple food items were not dated correctly. 2. The ice machine was observed to have black residue inside the ice bin and the water filter for the ice machine was 45 days past the due date to be changed. These failures had the potential for food contamination, which could result in food borne illnesses for all residents who consume food from the kitchen. The census was 42.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control procedures when: 1. Continuous Positive Airway Pressure (CPAP- a device that delivers oxygen) machine mask and tubing were not stored in a sanitary manner. 2a. Enhanced Barrier Precautions (EBP- infection control procedures to lessen the risk of cross-contamination) were not implemented for three rooms and, 2b. Visitors were not educated regarding the need for hand hygiene. This failure had the potential for the spread of infection to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to offer and/or provide education regarding the benefits and potential side effects of the pneumococcal (a type of bacterial lung infection) vaccine to four of ten residents (Residents 18, 71, 105, and 201) reviewed for immunizations. This failure posed the risk of the residents contracting pneumonia and its associated complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure four of ten residents sampled for immunizations were offered the Covid-19 vaccine. This failure resulted in the potential for residents to be infected with or experience complications from Covid-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care plans for two of 42 residents for: 1. Dialysis (a process to remove waste products from the blood stream, Resident 16) and, 2. Substance use disorder and nicotine dependence (Resident 151). As a result, Resident 16 and Resident 151's care needs, goals and interventions were not addressed or communicated to staff members for continuity of care. Cross reference:

Inspectors wroteBased on interview and record review, the facility failed to provide pain management for one of two residents (Resident 200) reviewed for pain management when pain medication was not administered per physician's order for severe pain. This failure had the potential to prevent Resident 200 from receiving adequate pain relief.

Inspectors wroteBased on observation, interview and record review, the facility failed to remove the dressing from a dialysis (treatment to remove waste from the body) access site for one of one residents reviewed for dialysis care (Resident 16). This failure had the potential to result in damage to the dialysis access site.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services for substance use disorder (a disease that affects a person's inability to control the use of a legal or illegal drug or medicine) and nicotine dependency (a state of physical or psychological habit) to one resident, Resident 151. As a result, Resident 151 had the potential to experience cravings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a medication was given as ordered by the physician for one of 14 sampled residents (Resident 106). This failure had the potential to affect the health and well-being of Resident 106.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's mediation error rate was 7.14%. Two medication errors were observed, a total of 28 opportunities, during the medication administration process for two of three randomly observed residents (Residents 1, 31, and 104). As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents safety when a resident (Resident 1) eloped from an unsecured exit. As a result, Resident 1 had a successful elopement (leaving the facility unsafely or unescorted), was found on the street by an officer and was returned back to the facility with no injury. This had the potential for residents with cognitive impairment (poor insight) to elope from the facility. In addition, this had the potential for unrestricted and unsafe access to the facility by persons without a need to be on the facility's property.

Inspectors wroteBased on observation, interviews and document reviews, the facility failed to ensure recipes were followed and appropriate measuring tools were used during pureed food production for seven residents. As a result, the residents were at risk of not receiving adequate nutrition, which could further compromised their health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure kitchen sanitation was maintained 2. All food temperatures were checked prior to the start of trayline This failure had the potential to place the residents at risk of foodborne illness. The facility census was 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine nail care to one of one resident (Resident 8), reviewed for Activities of Daily Living (ADL, activities related to personal care) for dependent residents. As a result, Resident 8 was at risk for skin injury and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician's orders for two of five residents reviewed for nutrition (22, 25). This failure had the potential to result in poor diabetes management, choking hazards, and further health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently provide dialysis (treatment to remove waste from the body) access care, including removal of dressing and assessment of the site, for one of two sampled residents (152), reviewed for dialysis. As a result, there was the potential for complications after dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. Three medication errors out of 29 opportunities were identified during medication (med) pass administration. As a result, the facility's medication error rate was 10.34%.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the policy for food brought by family or visitors for residents was implemented. This failure had the potential to result in the facility's 50 residents consuming foods not allowed on their physician-ordered diets.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when a Licensed Nurse (LN) 14 did not utilize appropriate hand hygiene and glove technique while administering medications (meds) through a resident's gastrostomy tube (g-tube, a tube surgically inserted to the stomach for food and administration of medications and fluids), for one of four sampled residents (Resident 28) observed during medication administration. This failure had the potential for infection to Resident 28.