Arvin Post Acute

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for one of two sampled residents (Resident 2) when the care plan did not address the protection of Resident 2 from further physical harm after Resident 1's Family Member (FM) hit Resident 2 in the face with a pillow. This failure had the potential to result in Resident 2 experiencing additional physical assault and potential for injury.

Inspectors wroteBased on interview and record review, the facility failed to timely develop and implement a care plan for the prevention and treatment of pressure injuries (a localized injury to the skin and/or underlying issue usually over a bony prominence, as a result of pressure, or pressure in combination with a shear) for two of three sampled residents (Resident 6 and Resident 28). This failure placed Resident 6 and Resident 28 at risk for developing pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. Expired and opened sterile (processed to prevent infection) wound treatment supplies were removed from storage and disposed of. This failure had the potential to result in expired and opened wound treatment supplies being used for residents' care and preventing wound healing and causing infection.2. One of three sampled residents (Resident 28) at risk of falls had fall risk assessments completed after falls. This failure placed Resident 28 at risk of falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility:1. Failed to ensure the ice machine was sanitized (disinfected) according to manufacturer's instructions.2. Failed to ensure a visitor wore a hair net while in the kitchen. These failures placed residents at risk of consuming contaminated food and beverages.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Psychoactive/Psychotropic Medication Use, for one of two sampled residents (Resident 12) when his informed consent for psychotropic (medication to treat mental disorders) medication was not completed. This failure had the potential for Resident 12 to receive psychotropic medication without knowing the risks and benefits of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 34) was provided enough electrical outlets when Resident 34 was unable to plug in her television and refrigerator at the same time. This failure resulted in Resident 34 not being able to use her television.

Inspectors wroteBased on interview and record review, the facility failed to inform and/or obtain Advance Directive (AD - written statement of person's wishes regarding medical treatment and end of life decisions, made to ensure those wishes are carried out should the person become unable to communicate their wishes) options for three of 24 sampled residents (Resident 11, Resident 72, and Resident 6). This failure had the potential for residents' end of life wishes to not be honored.

Inspectors wroteBased on interview and record review, the facility failed to notify ombudsman (representatives who assist residents in long-term care facilities with issues related to day-day care, health, safety, and personal preferences) of four of four sampled residents (Resident 11, Resident 12, Resident 6, and Resident 80) planned transfers and discharges. This failure had the potential to result in Resident 11, Resident 12, Resident 6, and Resident 80 not having an advocate who could inform them of their admission, transfer, and discharge rights and options.

Inspectors wroteBased on interview and record review, the facility failed to provide the complete Baseline Care Plan (BCP- initial instructions for care of the residents) for two of six sampled residents (Resident 3 and Resident 11). This failure had the potential to result in staff being unaware of residents' needs.

Inspectors wroteBased on interview and interview, the facility failed to ensure one of three residents (Resident 105) was offered and provided showers when requested. This failure resulted in Resident 105 only showering once during a seven day period.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of three residents (Resident 43) receiving tube feedings was kept with his head elevated at least 30 degrees while receiving tube feedings. This failure placed Resident 43 at risk of aspiration (food or liquid going into the lungs causing disease and respiratory problems).

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (RN) was on duty eight hours a day, seven days a week. This failure had the potential for resident care to be negatively impacted.

Inspectors wroteBased on interview and record review, the facility failed to ensure Performance Evaluation (PE - a process to give employees feedback on their job performance) for five of five sampled employees (Certified Nursing Assistant [CNA] 1, CNA 2, CNA 3, CNA 4, CNA 5) were completed. This failure had the potential for the staff not to be aware of their need for improvement in certain areas, which could affect resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe administration of medications when medications were found at Resident 33's bedside table without a medication self- administration assessment or a physician order for one of 24 sampled resident (Resident 33). This failure had the potential for medications to be administered incorrectly and unsafely.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 56 and Resident 43) were provided care using Enhanced Barrier Precautions (EBP - use of gowns and gloves to reduce transmission of multi-drug resistant organisms). This failure had the potential to result in Resident 56 and Resident 43 developing an infection.

Inspectors wroteBased on interview and record review, the facility failed to send one of three sampled residents (Resident 1) to the hospital promptly for evaluation and treatment of a left leg injury after Resident 1 reported she had injured her left leg and requested to be taken out to the hospital for X-rays (medical imaging to visualize the inside of the body, particularly bones and dense tissues) and treatment, delayed for six days until Resident 1 was taken to the hospital for evaluation and treatment for the left leg fracture (broken bone). This failure resulted in Resident 1 experiencing continued severe pain in her left leg which required hospitalization and surgical intervention.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on abuse, neglect, exploitation or misappropriation reporting and investigating when: 1. The facility did not complete a follow-up investigation report (FIR) after a resident-to-resident altercation (RRA) within five days for two of seven sampled residents (Resident 1 and Resident 2). This failure had the potential for Resident 1 and Resident 2 to have another altercation, and to develop distress and injuries. 2. The facility did not report an allegation of financial abuse to California Department of Public Health (CDPH) within 24 hours of an allegation for one of seven sampled residents (Resident 3). This failure had the potential for emotional distress for Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) responsible party (RP) was notified of a change of condition (COC). This failure had the potential for Resident 2's RP not to be aware of Resident 2's COC.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary condition in the kitchen with known infestation of cockroaches as evidenced by: 1. On 12/17/24 and 12/18/24 observed live cockroaches in the kitchen identified as German Cockroaches by the pest control service technician. 2. The kitchen staff do not clean and sanitize the kitchen counters prior to food preparation with known cockroach infestation. This involved nocturnal behavior of cockroaches which are highly likely to be contaminating food contact surfaces during the night. 3. In addition, cockroaches carry germs that can contaminate and had the potential to lead to foodborne illness for highly susceptible residents receiving food from the kitchen. 4. Failed to maintain an effective Pest Control Program. [...]

Inspectors wroteDuring a concurrent interview and record review on 12/17/24 at 10:39 a.m. with Nurse Consultant (NC) 1, Resident 30's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 30. During a concurrent interview and record review on 12/17/24 at 10:40 a.m. with NC 1, Resident 59's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 59. During a concurrent interview and record review on 12/17/24 at 10:42 a.m. with NC 1, Resident 64's medical record, was reviewed. NC 1 was unable to find documentation of an AD for Resident 64. During a review of the facility's P&P titled, Advance Directives, dated 9/2022, the P&P indicated,1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and implement nationally recognized infection prevention and control practices for seven of seven sampled residents (Resident 12, Resident 30, Resident 33, Resident 43, Resident 49, Resident 183, and Resident 379) as evidenced by: 1. Linens stored for two of two sampled residents (Resident 33 and Resident 183) on the bedside table inside Resident 33 and Resident 183's room. 2. Resident 12 and Resident 43's hands were not cleansed prior to eating lunch. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective Pest Control Program when live cockroaches were repeatedly found in the kitchen. This failure placed 70 of 72 highly susceptible sampled residents, at risk for foodborne illnesses when receiving food from the kitchen infested with cockroaches.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure the physician provided the informed consent (the process in which a health care professional educates a patient about the risks, benefits, and alternatives of a given procedure or medication) on the use of antipsychotic (drugs that treat psychosis [mental distress, mental disorder] and related conditions and symptoms) medication for one of one sampled resident (Resident 43) prior to the verbal consent obtained from Resident 43's representative. This failure had the potential for the resident and/or the resident representative to not receive the appropriate information regarding the drug, its indication, side-effects, and make the right decision. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure confidentiality of Private Health Information (PHI) was maintained for two of two sampled residents (Resident 25 and Resident 58). This failure resulted in Resident 25 and Resident 58's PHI being compromised and seen by unauthorized personnel.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Personal Property, for two of two sampled residents (Resident 30 and Resident 21) when: 1. Resident 30's belongings were not inventoried and documented on admission. 2. Resident 21's clothing went missing in the facility. These failures had the potential to negatively affect the resident's psychosocial well-being and had the potential to result in lack of reimbursement for lost belongings.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Baseline Care Plan (BCP- outlines a process for development of an initial person-centered care plan within the first 48 hours of admission, that will provide instructions for care of the resident) was completed for one of one sampled resident (Resident 12) within 48-hours of admission and a summary provided to the resident and/or resident representative. This failure had the potential for Resident 12 to not receive the care and the safeguards necessary within the 48-hour of admission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for personal grooming, including care of the fingernails for one of one sampled resident (Resident 12). This failure had the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan after a change of status for Hospice (end of life care) services for one of two sampled residents (Resident 25). This failure had the potential for Resident 25 to receive Hospice services when no longer needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oral care was rendered for one of one sampled resident (Resident 33) to maintain oral hygiene. This failure had the potential for Resident 33 to acquire oral infections, tooth decay, or gum disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement person center quality care for one of one sampled resident (Resident 10) when Resident 10's fingernails were not trimmed, hand splint was not applied and, physician's order for surgical consultant was not procesed. This failure resulted in delayed care for Resident 10 and had the potential for adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide foot care and podiatry (foot specialist) referral for one of one sampled resident (Resident 33). This failure resulted in Resident 33's feet and toenails to be left untreated.

Inspectors wroteBased on interview and record review, the facility failed to manage and document pain accurately for one of one sampled resident (Resident 12). This failure had the potential for Resident 12 to not be able to function and perform daily activities and improve quality of life.

Inspectors wroteBased on observation, interview, and record review, the Dietary Manager (DM) failed to demonstrate competency to carry out the functions of the food and nutrition service for all the residents residing in the facility when there was a multi-generational cockroach infestation in the kitchen. This failure resulted in no action plan put in place to address and meet the health and safety needs for the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Admissions Coordinator (AC) had the full understanding of the Binding Arbitration Agreement (BAA-the parties waive their right to a trial and agree to accept the arbitrator's decision as final) to be able to explain the content of the BAA for three of 47 sampled residents (Resident 7, Resident 8, and Resident 64) in the manner, form, and language understood by the resident and/or resident representative. This failure had the potential for Resident 7, Resident 8, and Resident 64 and/or their representatives to be misinformed and not fully understand the terms and conditions stipulated in the arbitration agreement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary shower area was provided for the residents. This failure had the potential for injury and spread of infectious disease to facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1 and Resident 2) were free from verbal abuse. This failure resulted in Activity Assistant (AA) verbally abused Resident 1 and Resident 2 during activities and had the potential to cause emotional harm.

Inspectors wroteBased on interview and record review, the facility failed to complete an investigation of a verbal abuse allegation within five working days for one of four sample residents (Resident 1). This failure had the potential to place Resident 1 at risk for suffering continuous verbal abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure laundry was cleaned and sanitized according to the manufacturer's guidelines. This failure had the potential to result in the transmission of infection and communicable diseases to all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) care plan was implemented. This failure had the potential for Resident 2 to have unmet care needs.

Inspectors wroteBased on interview and record review, the facility to ensure fall risk assessments were completed for one of three sampled residents (Resident 2). This failure had the potential for staff not to be aware of Resident 2 ' s risk for falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan was developed and implemented after a change of condition for one of two residents (Resident 1). This failure had the potential for Resident 1 not to receive need medical treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate nutrition for one of 44 sampled residents (Resident 44) when: 1. The nursing staff did not notify the Primary Care Physician (PCP) and the Family Member (FM) 2 of Resident 44's unplanned weight loss. 2. A care plan addressing unplanned weight loss was not developed and implemented. 3. Ensure the Interdisciplinary Team (IDT - a group of healthcare professionals who work together to provide beneficial care to the residents) addressed the significant weight loss. 4. Dietary recommendations by the Registered Dietician (RD) were not implemented. These failures resulted in Resident 44's unplanned total weight loss of 39 lbs (Pounds-unit of measure) (-15.4%) in 45 days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly maintain sanitary kitchen and food storage areas. These failures had the potential to spread food borne illness to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan for one of 44 sampled residents (Resident 50). This failure had the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label a multiple-dose insulin (regulates the amount of glucose in the blood) pen (an injection device with a needle that delivers insulin underneath the skin) in the medication cart. This failure had the potential for medication to be given to the wrong resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and facilitate smoking activity for one of 44 sampled residents (Resident 49). This failure resulted in Resident 49's inability to exercise his rights regarding activity preferences.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment (CA) after a significant change in the resident's condition for one of 44 sampled residents (Resident 44). This failure had the potential to result in delay of treatment, planning of care, and provision of appropriate services for Resident 44.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities to identify health problems) reflected the accurate status for one of 44 sampled residents (Resident 49). This failure had the potential to negatively affect Resident 49's plan of care and delivery of services.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a physicians order for one of 44 sampled residents (Resident 39) when a positioning device was not implemented. This failure had the potential for skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistive care was provided for two of 44 sampled residents (Resident 26 and Resident 39). This failure had potential for emotional discomfort and decline in functional abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure restorative nursing services (person-centered care designed to improve or maintain the functional ability of residents) were provided for one of 44 sampled residents (Resident 39). This failure had the potential for Resident 39 to not maintain his highest level of physical function.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate was five percent or less when two medication errors were observed out of 26 medication administration opportunities, which yielded a medication error rate of 7.69 percent. These failures had the potential for residents to not receive the therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards, when staff didn't perform hand hygiene. This failure had the potential to spread illness and disease to two of 44 residents (Resident 21 and Resident 221).