Central Gardens Post Acute

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Level I Pre-admission Screening and Resident Review (PASARR) accurately reflected the presence of diagnosed mental illnesses for 1 (Resident #7) of 3 residents reviewed for PASARR requirements. Specifically, Resident #7 had a Level I PASARR completed upon readmission to the facility that did not reflect all their mental health diagnoses.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to maintain a medication error rate of less than 5 percent (%). Specifically, the facility had 2 errors out of 30 opportunities, resulting in a medication error rate of 6.67 %, affecting 1 (Resident #39) of 6 residents observed during medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) when providing care to 1 (Resident #155) of 1 resident requiring EBP observed during the provision of care. Specifically, staff failed to wear a gown during resident care that consisted of touching the resident and their feeding tube.

Inspectors wroteBased on Interviews and record reviews, the facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility ' s policy and procedure for four of 4 sampled residents (Resident 1, Resident 2 Resident 3, and Resident 4). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plan was developed within 48 hours of admission for Resident 6 and a copy of the baseline care plan summary was provided to the resident and/or representative for three of 3 sampled residents (Resident 5, 6, and 7). A Baseline Care Plan (BCP) includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. The deficient practice resulted in Resident 5, 6, and 7, and/or RP not receiving information of the initial plan of care; [...]

Inspectors wroteBased on interview, record review, and observation, the facility failed to provide needed care and assistance in accordance with professional standards of practice when Resident 1, one of one sampled residents, did not receive pain medication or bathroom assistance, throughout the entire night. This failure caused undue suffering and neglect to the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a medication error rate less than five percent for two out of seven Residents observed (Residents 53 and Resident 8). This created an error rate of 9.68 percent (3 errors out of thirty-one opportunities). This failure had the potential to cause worsening medical conditions for each resident. Findings. 1. Symbicort was not administered during the appropriate time frame for Resident 53 (omission of medication). 2. Depakote delayed release tablets was crushed and administered for Resident 8. 3. Lidocaine patch was not applied to Resident 8 and documented as administered (omission of medication). 1. During an observation on 5/23/23 at 9:49 AM in Resident 53's room, it was observed that licensed vocational nurse (LVN) 1 administered tablet medications only to Resident 53. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment when: 1. The Red Zone (isolation room) door, with Resident 434 inside, was fully open while staff was cleaning the room. 2a. A dirty urinal was hung on the side rail of Resident 44's bed on 5/23/23. 2b. Resident 44's urinal jug containing urine was placed on the overbed table. 3. Staff did not perform hand hygiene after glove removal. 4. Staff did not perform hand hygiene when she entered between two residents' rooms. 5. Staff did not clean and disinfect medical equipment (blood pressure cuff) in between multiple residents (Resident 39, Resident 53, and Resident 44). These failures had the potential for cross contamination of infection that can compromise the health and safety of the residents and the potential to spread infectious disease from one resident to another.

Inspectors wroteBased on interview and record review, the facility failed to create a baseline care plan based on physician admitting order of one of three residents (Resident 78) reviewed when Resident 78 admitted [DATE] with enteral feeding order, care plan was only initiated on 5/24/23. This failure can result in Resident 1 not getting tube feeding as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement fall care plan for one of three sampled residents (Resident 6) when there was no landing pad (known as fall mat) in place after his fall incident on 2/20/23. This failure placed Resident 6 at risk for injury from another fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the fall care plan for one of three sampled residents (Resident 6) after his fall incident on 10/26/22. This failure had the potential to put Resident 6 at risk for another fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an accurate accountability sheet that documented the number of controlled substances (Oxycodone tablets, pain medication) that should be available for destruction, and an accurate count of controlled substance (Oxycodone tablets) physically available for destruction compared to the documented amount that should be available for destruction for one out of eight residents reviewed (Resident 441). This failure has the potential to cause medication diversion (illegal use of medication not intended by the provider).

Inspectors wroteBased on observation, interview, and record review the facility failed to store controlled substances intended for destruction in a separately locked and permanently affixed storage compartment when Oxycodone (controlled substance for pain) tablets and solutions were found on the floor, and in a cardboard box in plain sight, for one out of seven Residents reviewed (Resident 441). This failure had the potential to cause medication diversion (illegal use of medication not intended by the provider). Findings. Review of Resident 441 admission Record indicated that Resident 441 was admitted on [DATE], with the medical diagnoses including left hip osteoarthritis (joint and bone disease causing pain and stiffness) , Pain in left lower leg, and kidney failure. Resident 441 was discharged from the facility on 1/09/23. [...]

Inspectors wroteBased on observation, interview and, record review, the facility failed to accommodate food preferences of one of nine sampled residents (Resident 11) when she was served cheeseburger instead of the preferred pork vegetable stir fry during lunch on 5/25/23. This deficient practice had the potential for Resident 11 to experience an unpleasant dining experience due to receiving foods she did not request or like.

Inspectors wroteBased on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety when: A. 16 cups of juices, six thickened milk were not dated and not labeled; B. The refrigerator for resident food in nurse station A was not clean; C. Three cutting boards had rough, deep scratches; one cutting board had dark residue on the surface; D. Four large sheet pans had dark brown/ black thick residue on the inside surface; E. Three muffin pans had dark brown and sticky yellow residue on the inside surface; and F. Three non stick pans had rough, scratched inside coating; one with broken handle. These failures had the potential to cause food borne illness for 83 residents who received food from the kitchen out of the facility census of 83.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment to prevent the development and transmission of communicable diseases and infections when: 1. CNA 2, without wearing gloves, transported unbagged, soiled laundry from a resident's room to a hamper in the shower room. 2. An unlabeled, uncovered urinal, with scant yellowish liquid, was found on Resident 13's bedside table. 3. Licensed Vocational Nurse (LVN) 1 did not observe infection control techniques when administering Resident 10's eye drop medication. 4. LVN 1 did not handwash in between patient care. 5. Multi resident use glucometer was not disinfected according to disinfecting wipes' directions for use 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to give adequate and timely notice of Medicare coverage end date for three of three sampled residents, Resident 7, Resident 30, and Resident 84, when: 1. No evidence Resident 7 received Notice of Medicare Non Coverage (NOMNC - a notice that informs Residents of their Medicare Part A coverage end date and how to appeal). 2. Residents 30 and Resident 84 received NOMNC on the same day their coverage ended. These failures resulted in Resident 7, Resident 30, and Resident 84 not being sufficiently informed of their potential financial responsibility or their right to appeal termination of Medicare Part A (insurance that covers skilled services like physical therapy) in an acceptable amount of time.

Inspectors wrote2. Review of clinical record titled Minimum Data Set (MDS, a resident assessment tool), for Resident 82, dated 9/23/19, indicated a Brief Interview for Mental Status (BIMS, a brief assessment to help detect cognitive impairment) score of 15 indicating resident is cognitively intact. Resident 82 had diagnoses that included type 2 diabetes mellitus (high blood sugar), cellulitis (a common and potentially serious bacterial skin infection of left upper limb) and schizoaffective disorder (a mental health condition including schizophrenia and mood disorder symptoms). Review of the clinical record for Resident 82, the document titled, Order Summary Report, dated 10/1/19, indicated, Insulin Aspart Solution inject as per sliding scale: if 0 69=0 initiate hypoglycemia protocol; 70 130=0;131 180=4; 181 240=8; 241 300=10;301 350;12; 351 400=16; 401 500=20 given insulin and call MD . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5% when six errors were observed in 25 opportunities which resulted in a 24% medication error rate. The errors were as follows: 1. Cilostazol (medicine that prevents the formation of blood clots) was not administered according to manufacturer's specification for two of nine residents (Residents 42 and 38). 2. Sevelamer (a phosphate binder, limits absorption and decreases phosphate concentrations in the blood) was not prepared according to physician's orders for one of nine residents (Resident 7). 3. Multivitamins with minerals was not administered according to physician's orders for one of nine residents (Resident 38). 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents were free of significant medication errors when two of 17 sampled residents (Resident 11 and 42) were administered insulin (a hormone that lowers the level of blood sugar) that had beyond use by date. This deficient practice had the potential to negatively affect Resident 11 and 42's health and safety and may lead to unnecessary treatment and/or hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmaceutical services to meet the needs of residents when: 1. In Side A medication cart, the following medications were found: 1a. Seven (7) opened multi dose vials of insulin (a hormone that lowers the level of blood sugar) were stored beyond use date 1b. Four (4) opened, undated multi dose vials of insulin 1c. One (1) opened, undated multi dose insulin pen (a device that help people inject insulin. It contains a cartridge, a dial to measure dosage, and a disposable needle) 1d. Five (5) opened, undated multi dose inhalers (a portable device for administering a drug which is to be breathed in, used for relieving asthma and other bronchial or nasal congestion) 2. In Side B medication room, a box of rectal suppositories was stored with oral medications and tube feeding formulas. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain or enhance three of 22 sampled residents' dignity and respect in full recognition of their individuality when Certified Nursing Assistant (CNA) 1 stood over them as she assisted with their meals. This failure prevented the residents from exercising their right to have a dignified existence, and quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility's Interdisciplinary Team failed to complete an assessment to determine the appropriateness to self-administer medication for one of one sampled resident (Resident 485) when one bottle of fluticasone nasal spray (medication used for relief of allergic nasal symptoms) and a tube of desonide cream (medication used for relief of itchiness) were found at Resident 485's bedside table. This failure had the potential for Resident 485 to overuse the medications which can lead to untoward effects and for Resident 485 to feel inadequate.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 22 sampled residents (Residents 15 and 7) received appropriate treatment and services to maintain and improve range of motion (ROM) when the physician's order for Restorative Nursing Assistant (RNA) program was not implemented. This deficient practice had the potential for Residents 15 and 7, to experience reduction in range of motion.

Inspectors wroteBased an observation, interview and record review, the facility failed to provide an environment that is free from accidents when one of 22 sampled residents (Resident 11) two upper bed rails were broken. This deficient practice had the potential for Resident 11 to have an accident, which may result in injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate medical record for one of 22 sampled residents (Resident 82) when licensed staff did not sign and document in the Medication Administration Record (MAR) on eight (8) medication administration opportunities and one (1) blood sugar check reading. This failure had the potential to result in improper communication between licensed nurses that may adversely affect potential medication error.