Bancroft Healthcare Center

Inspectors wroteBased on interview and record review, licensed nursing staff did not provide care according to professional standards for 1 of 3 sampled residents (Resident 1). Resident 1 had been prescribed oxycodone (narcotic) since 2024 and was in hospice (end-of-life care for a terminal illness.) When Resident 1 could no longer swallow her pills, facility staff did not have a plan in place to address withdrawal symptoms from the oxycodone. This resulted in Resident 1 experiencing unnecessary pain, agitation and distress. During a review of Resident 1's clinical document titled admission Record, the admission record indicated, the facility admitted Resident 1 on 12/14/2023 with multiple medical diagnoses including multiple fractures, cerebral infarction (stroke) and chronic pain syndrome. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for four out of 14 sampled residents (Residents 17, 2, 22 and 24). This failure had the potential for the facility to provide treatment and services against the residents' wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two sampled residents' (Resident 4 and 21) rooms had comfortable and safe temperature levels. This failure had the potential to cause overheating in residents and discomfort during severe hot weather.

Inspectors wroteBased on observation, interview and record review, the facility failed to use the communication binder (a communication visual tool that is used to help residents communicate their needs) for three of three sampled non-English speaking or aphasic (a language disorder that affects how you communicate) residents (Resident 25, Resident 24, and 17) when: 1. Resident 25 and 24's communication binders were not used, and 2. Resident 17 did not have a communication binder. This failure had the potential for Residents 25, 24 and 17 not to understand and carry out activities of daily living (ADL).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), accurately reflect the assessment status for two (Resident 4 and 12) of fourteen sampled residents when 1. Resident 4's MDS section G did not reflect limitation in range of motion to upper and lower extremities (hip, knee, ankle, foot), and 2. Resident 12's MDS section K did not reflect a significant weight loss. These failure had the potential for residents to not receive appropriate care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 32) sampled resident on tube feeding (Tube feeding refers to the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum. It is also referred to as an enteral feeding.) maintained acceptable nutritional status and body weight range when Resident 32's unplanned weight loss was not reevaluated with appropriate interventions by the Registered Dietician (RD), and the facility did not notify the physician and responsible party of Resident's 32 unplanned weight loss. This failure had the potential to result in Resident 32's dehydration and unplanned weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 18) sampled resident was free from unnecessary drugs when Resident 18 with diagnosis of Alzheimer Dementia was administered Seroquel (Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior) medication without adequate clinical indication for continued usage. This failure had the potential for Resident 18 to receive unnecessary medications and had the potential for the Resident 18 to suffer adverse medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when: 1. One box of expired blood glucose test strips (small, disposable plastic strips that measure blood sugar levels) for Resident 137 was stored in the medication room, 2. A bottle of liquid Lorazepam (medication used to treat anxiety) which belonged to a deceased resident was stored in the refrigerator in the medication room, and 3. A bottle of expired Senna (laxative) tablets was stored in the medication cart 2. These failed practices could contribute to unsafe medication use in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident 7) sampled resident received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician when Certified Nursing Assistant (CNA 5) served Resident 7 a meal tray of pureed diet that belonged to Resident 13. This failure had the potential to cause residents to receive and consume foods that are not in the appropriate texture and nutrient content to support the resident's needs cause choking or food allergy.

Inspectors wroteBased on observation and interview, the facility had one residents' room (room [ROOM NUMBER]) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied this room. This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings.

Inspectors wroteBased on interview and record review, the facility failed to inform residents in a language they understood of their rights, all rules and regulations governing residents conduct and responsibilities during their stay at the facility for nine of nine sampled residents (Resident 5, 6, 8, 11, 21, 24, 25, 27 and 133), who were identified as Chinese speaking residents. A California ombudsman essentially helps senior victims of abuse or neglect to understand their rights within the legal system and reach a proper resolution}. This failure had the potential to cause residents emotional distress and despair.

Inspectors wroteBased on observation and interview, the facility failed to ensure storage of food under sanitary conditions when; - one carton of thickened Apple Juice from concentrate was opened with no use- by-date; - three containers of mayonnaise opened with no use-by-date; - five brownish, discolored juice cups ready for use; - one container of chopped garlic in oil opened with no use- by-date; - staffs' personal food items of tea, cooked eggs and cell phone were placed on the kitchen preparation table; - two bags of vegetables placed on the 2-compartment sink next to dishwashing area. These failures had the potential to result in food borne illness for residents who received food from the facility's kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one (Resident 24) sampled resident's Pre-admission Screening Resident Review (PASRR) for serious mental illness was accurately completed and referred to the appropriate state mental authority for Level II evaluation and determination. This failure had the potential to prevent Resident 24 from receiving appropriate required mental health services.

Inspectors wroteBased on interview and record review, the facility failed to implement the nutritional interventions for one (Resident 29) of one sampled resident with significant weight loss. This failure had the potential to result in continuous weight loss, fluid imbalance, and dehydration.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (Resident 20) of five sampled residents was free from unnecessary drugs when the pharmacist's recommendation for reviewing the justifciation of the continued use of Benadryl (antihistamine/allergy) medication ordered PRN (as needed) was not acted upon. Definition: Benadryl is an antihistamine drug use for relief of allergic symptoms with warning that included central nervous depression which may impair physical or mental abilities, patient must be caution about performing tasks that required alertness}. Reference: https://online.[NAME].com. This failure had the potential for adverse medication side effects and not identifying other causes of itchy skin (dry skin, allergic reactions or other skin conditions).

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use alternatives, explain the risk and benefits and obtain informed consent from the resident and resident representative (RR) prior to installment of the bed side rails for 29 out of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25). Also, there was no side-rail assessment conducted prior to initiation of the bed side rails for Resident 30. The facility's failure to assess bed side rail use for Resident 30 placed Resident 30 at risk for entrapment and injuries. Also, these failures resulted in 29 of 29 residents and their RR's to be unaware of risks and benefits of side rails and to be able to make an informed decision. [cross reference F835]

Inspectors wroteBased on observation, interview, and record review, the facility's administration failed to identify, update and implement it's outdated policy and procedure for bed side rail use. The facility failed to administer bed side rails without reviewing risks and benefits; obtaining an informed consent from residents/ resident representatives; and without using less restrictive alternatives prior to installing bed side rails to 29 of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25) residing at the facility. This failure placed all 29 residents residing at the facility at risk for avoidable injuries. [cross reference F700]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of 12 sampled residents (Resident 27) with respect and dignity when: 1. Resident 27 had a clothing protector, commonly known as bib on for over three hours after breakfast hours; and 2. Registered Nurse (RN 1) addressed Resident 27 as [NAME] during incontinent care. These failures resulted in Resident 27 to not receive individualized care and had potential for Resident 27 to not feel respected.

Inspectors wroteBased on observation and interview, the facility failed to ensure privacy and confidentiality of medical information for two of two sampled residents (Residents 23 and 30) when: 1. Resident 30's electronic medical record was left exposed at Medication Cart 1; and 2. Certified Nursing Assistant 3 (CNA 3) did not provide privacy during toileting for Resident 23. These failures had the potential for unauthorized access to Resident 30's medical information and it violated resident's right to privacy for Resident 23.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a home like environment to five of 12 sampled residents (Resident 1, 23, 2, 8 and 30) when: 1. the room temperature for Resident 1 and 23 were too cold; and 2. the overbed tables for Residents 2, 8 and 30 were rough and unfurnished. The above failures resulted in Resident 1 and 23 feeling cold, and the potential for Residents 2, 8 and 30 getting scratched and hurting themselves.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure its medication error rate did not exceed five percent for one of 12 sampled residents (Resident 27). There were four medication errors out of 25 opportunities resulting to 16 percent (%) medication error rate when Resident 27's percutaneous endoscopic gastrostomy tube (PEG tube, a feeding tube placed through the abdominal wall and into the stomach that allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth ) was not flushed (inserting a liquid substance into a tube, usually ) with water in between administering Apixaban (blood thinner medication), Ascorbic Acid (Vitamin C supplement), Doxazosin Mesylate (high blood pressure and urinary retention medications), and Vitamin D3 (Vitamin D supplement). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the lunch menu for 12 of 12 sampled residents (Residents 31, 26, 28, 8, 2, 17, 24, 30, 20, 11, 5, 1, 19, 14 and 7) and the Dietary Department did not notify the residents of the menu change. This deficient practice resulted in Residents 31, 26, 28, 8, 2, 17, 24, 30, 20, 11, 5, 1, 19, 14 and 7 not knowing what food items they were getting for lunch and had the potential for residents not to get the nutritional value of the food item that was on originally on the menu.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the physician's order to provide a fortified diet (food that has extra nutrients added to it or has nutrients added that are not normally there) for two of 12 sampled residents (Residents 5 and 28). This deficient practice had the potential to cause Residents 5 and 28 to experience weight loss and to not meet or maintain their ideal body weight.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: 1. an opened lemon juice bottle, three turkey meat slices wrapped in foil, and one turkey pack with no open date were found in Refrigerator 2 (Ref 2), 2. one sliced banana in plastic wrap and five slices of oranges in an uncovered bowl with no prepared date were found in Refrigerator 1 (Ref 1), 3. one overripe banana was in Ref 1 and 11 overripe bananas was in the dry storage room, 4. Ref 1 had black crumbs on the door latch and had dried liquid drippings on Ref 1's back wall, 5. the can opener had dried matter and white hair stuck on it, 6. the dry storage area did not have a thermometer, 7. staff did not wash their hands and change gloves in between touching food items, handles, and their face mask; and 8. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the proper disposal and refuse of garbage when the trash bin inside the kitchen did not have its lid on for four hours, and the dumpster outside the facility was left open. This deficient practices had the potential to attract rodents and insects and cross-contamination of food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their practices to maintain a clean and sanitary environment to prevent the spread of infections for five of 12 sampled residents (Resident 26, 16, 19, 25, and 27) when: 1. Resident 26 and 19's oxygen tubing was not dated and were observed on the floor and Resident 26's humidifier was not dated, 2. Resident 19's Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) was laying on the floor; and 3. Registered Nurse 1 (RN 1) did not perform hand hygiene before preparing medications for Resident 25, 16, and 27. These deficient practices had the potential to expose Resident 26, 16, 19, 25, and 27 to possible infection.

Inspectors wroteBased on observation and interview, the facility to ensure kitchen equipment was maintained when the dishwasher temperature gauge (a device that measures the dishwasher temperature) did not measure the correct dishwasher water temperature. This deficient practice resulted in inaccurate measurements and documentation of dishwasher water temperatures and had the potential for dishes to not be cleaned and sanitized at the recommended temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident 23) received the necessary services to maintain personal hygiene when Resident 23 did not receive incontinent (inability to hold urine or bowels) care. This deficient practice had the potential to make Resident 23 feel the lack of dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to record and document one controlled medication (medication with potential or risk for abuse) when Norco (medication for severe pain) was not recorded and documented on the facility's Narcotics (a drug or substance that affects mood or behavior) Log for one of 12 sampled residents (Resident 26). This deficient practice had the potential for loss or diversion of Resident 26's pain medication.

Inspectors wroteBased on observation and interview, the facility failed to provide one of one sampled resident in room [ROOM NUMBER] with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for the resident and staff to move about without obstruction. Recommend granting waiver.