Chico Terrace Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of three (Resident 1), who spoke Spanish was explained what medications were being administered to them in a language they understood. This failure had the potential to result in violating the resident's right to be informed of their treatment.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change of condition for one of three sampled residents (Resident 1), when Resident 1 was having loose stools for eight days before the physician was notified. This failure resulted in the physician being unaware of Resident 1's condition and unable to evaluate the resident for needed changes in the treatment plan.

Inspectors wroteBased on interview and record review, the facility failed to withhold (not give) a stool softener medication as directed by the physicians' orders for one of three sampled residents (Resident 1). This failure resulted in Resident 1 continuing to receive the medication despite experiencing diarrhea.

Inspectors wroteBased on interview and record review the facility failed to:Ensure uncertified Nurse's Aides (NA, in training not certified) did not provide direct resident care (hands on care) while unsupervised by a Certified Nursing Assistant (CNA, certified by state) or Licensed Nurse (LN). Ensure uncertified Nurse's Aide did not go beyond the time frame of four months between hiring, graduation, and certification. This had the potential to put all residents at risk of injury and not to meet their care needs. Refer to F839.

Inspectors wroteBased on interview and record review the Governing Body failed to provide oversight for the Administrator to ensure nurse's aides were state certified and had the competencies required prior to providing care to residents independently and were certified within four months of graduating from a Nurse's Aide Training Program Nurse's Aide Training Program (NATP, a state approved program designed to teach nurse's aides theory and clinical skills to enable eligibility to test for certification). This had the potential to put all residents at risk of injury and harm and to not receive quality of care when nine Nurse's Assistants (NA, in training not certified by state) were hired prior to becoming state certified to practice as Certified Nursing Assistants (CNA, certified by state). Refer to F728.

Inspectors wroteBased on interview, and record review, the facility failed to provide medical records for one out of four Residents (Resident 1) in a timely manner. This had the potential to interfere with Resident 1's care decision making and cause distress to his well-being. During a review of the facility's policy titled Resident Access to Protected Health Information (PHI), revised November 1, 2015, indicated If the resident and/or their personal representative requests a copy of the resident's medical record.[the facility] will provide the resident and/or their personal representative with a copy of the medical record within two (2) working days after receiving the written request. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent abuse to one resident (RES1), when a Licensed Nurse at the facility (LVN1) was verbally abusive while providing care to RES1. This failure had the potential to cause harm to all residents residing in the facility that had contact with LVN1.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure staff were trained, competent and following their training when: *1. Staff did not clean fixed equipment (equipment that cannot be put thought a dish washer or washed in a sink, such as refrigerators, steamers, stoves, carts, counters, shelving, and small appliances) according to policy or standards of practice. *2. Staff did not consistently follow professional standards of practice to avoid cross contamination during food production processes. (Cross Reference F812). *3. Staff did not follow standardized recipes.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that recipes were standardized to provide a repeatable desirable product, yield and texture; that appropriate ingredients were available on the order guide to prepare recipes successfully and in compliance with their nutrient analysis; and to provide seasoning acceptable to the diet order and resident satisfaction. These failures had the potential to result in staff not following recipes because they didn't work or didn't produce the correct yield or consistency, and the potential to decrease resident satisfaction, meal intakes, and overall health status.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all residents were consistently offered evening bedtime snacks per facility policy for four out of four sampled residents (Resident 372, 15, 59, 34). Facility also failed to ensure snacks were stocked at two out of two nursing stations per facility policy. This failure had the potential to negatively affect nutrition status and wellbeing of all residents. The facility census was 72.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared and distributed in accordance with professional food safety standards when: 1) Fixed equipment (Fixed equipment is equipment that cannot be put thought a dish washer or washed in a sink, such as refrigerators, steamers, stoves, carts, counters, shelving, and small appliances) was not clean. 2) Apron was not changed between cleaning dishes and preparing food. Apron was not worn when soiled counter was cleaned. 3) Dietary staff touched face with gloved hands when trays were loaded onto cart and did not change gloves or wash hands. Dietary staff touched tops and bottoms of dessert bowls and scooped Jell-O into them without gloves. 4) Cabinets, floors and walls were uncleanable. 5) Evidence of roaches under one sink. 6) Chlorine concentration was outside of acceptable parameters. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure conditions essential to the sanitation of the kitchen were maintained when uncleanable surfaces were not repaired or replaced. This failure had the potential to result in cross contamination, the attraction of pests, and foodborne illness for all residents consuming food from the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program when: *1. The facility did not have an effective system in place to track and monitor pest control issues in the facility. *2. Cockroach traps, and evidence of cockroach presence were found in a cabinet under a food preparation sink in the facility kitchen. These failures had the potential to result in transmission of disease, or to trigger allergies or asthma for 72 residents living at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of eight sampled residents (Resident 18 and Resident 370) received their showers as scheduled, and as needed. This failure had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and not identifying altered skin integrity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was palatable and meat easy to cut with a knife when four out of four residents interviewed (Resident 15, 18, 59, 372) stated the food needed more seasoning or salt and/or the meat was difficult to cut with the provided knife. This failure had the potential to result in decreased resident meal intakes, weight loss, and decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders for a suprapubic (S/P, a thin tube inserted directed into the bladder at the abdomen to drain urine) catheter changes and site care were obtained upon admission to the facility for one of three sampled residents, (Resident 18) for a new admission. This failure had the potential for a negative clinical outcome, re-hospitalization, and Resident 18 had specific skin treatment needs that were not identified in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 43) received coordination of care to get out of bed daily, and at meals to improve quality of life, and to meet goals towards independence to discharge home. These failures had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and prevent the resident from achieving their highest practicable level of physical and emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Certified Nursing Assistants (CNA)s, and the Licensed Nurses (LN)s had competent skills when: 1. CNAs and LNs did not provide Dementia care for Resident 35 when resident was left in the Dining room alone and fell. 2. LNs did not verbalize understanding of phosphorus binder medication administration for Resident 18 and Resident 373. 3. LN A was not able to verbalize instructions for use for an inhaler ordered for Resident 373. These failures had the potential to result in emotional stress, anger, depression, feelings of neglect, denial of resident rights, and prevent the resident from achieving their highest practicable level of physical and emotional well-being. These failures did result in a fall for Resident 35.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Care Conference meeting, to determine that a resident may be appropriate for a facility initiated discharge, occurred with the Interdisciplinary Team (IDT, a group of healthcare professionals nurses, therapists, social workers, dietitians and activities staff who work together to plan the residents care), Physician, the resident and resident ' s responsible party (RP, an individual who assumes varying degrees of responsibility for the well-being of the resident) for one of two sampled residents (Resident 1) when Resident 1 ' s RP indicated she never had a meeting with the facility about Resident 1 ' s discharge therapy levels or training on how to assist Resident 1 with his mobility at home and Resident 1 was unable to make it into the house and could not stand or transfer. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure they provided care and services for one of two residents (Resident 1) sampled for unplanned weight loss when: 1. Resident 1 was not weighed as per facility policy. 2. There was no weekly monitoring of Resident 1 ' s weight by an Interdisciplinary Team (IDT, a group of healthcare professionals nurses, therapists, social workers, dietitians and activities staff who work together to plan the residents care) the first 10 weeks after admission. 3. Care plan titled Nutritional problem or potential nutritional problem was not reviewed or revised to reflect an actual weight loss and no interventions were added to his care plan. These failures delayed care and services needed for Resident 1 to prevent weight loss and had the potential to add to the cause of Resident 1 ' s 18.8-pound weight loss in two months.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that is palatable (refers to the taste and/or flavor of the food), attractive, and nutritious. Complaints of food that is not appetizing or palatable for three of five (Residents 3, 5 and 6). This had the potential for all residents to receive an inadequate amount of nutrition required to aid in the recovery from illness or injury or maintain a healthy body weight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a food was prepared in a safe and sanitary kitchen in accordance with professional food standards when: 1. Food was stored in a refrigerator that was not maintained at the required temperatures for storage. 2. Food storage containers were stacked wet and available for use. 3. A soiled towel was used around a floor drain to prevent splashing. This had the potential to put all residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to identify and act upon a change in condition by notifying the physican of post fall pain for one out of six sampled residents (Resident 4). This resulted in delay of treatment which caused unnecessary pain and suffering. Findings A review of Resident 4 ' s admission record indicated he was admitted to the facility on [DATE], with diagnoses which included dysphagia and aphasia following a cerebral infarction (difficulty swallowing and talking following a stroke), muscle weakness, frequent falls at home and dementia. A review of Residents 4 ' s admission notes on 6/29/24 at 1:24 pm, by a Licensed Nurse (LN) indicated resident had no pain on admission. A review of Resident 4 ' s nursing progress note dated 7/1/24 at 5:06 am, indicated Resident 4 had an unwitnessed fall at 4:45 am on 7/1/24. [...]

Inspectors wroteBased on interview and record review the facility failed to develop a Person-Centered baseline care plan within 48 hours of a resident's admission to meet the resident's immediate needs for one of the 6 sampled residents (Resident 4). This failure placed Resident 4's health at risk when resident's person centered care plan was not created upon admission.

Inspectors wroteBased on interview and record review the facility to ensure one of six residents (Resident 4) had a plan of care to meet his pain management needs after a fall with substantial injury. This resulted in untreated severe pain and a delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff followed the dietary menus and a recipe for a lunch meal when: 1. An unapproved substitute meal was provided without reasonable effort made to ensure nutritional adequacy. 2. A recipe was not followed for creamy rice. This had the potential for all residents not to receive their nutritional requirements to maintain normal body weight.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that facility air temperatures were at a comfortable level for resident rooms and hallways on Station 2. These failures resulted in residents to feel uncomfortable, tired, horrible, and lost sleep.

Inspectors wroteBased on observations, interviews, record review, and facility policy, the facility failed to secure urinary catheter tubing for 1 (Resident #12) of 2 sampled residents reviewed for urinary catheter.

Inspectors wroteBased on interviews, record review, and facility policy titled, the facility failed to ensure an as-needed psychotropic medication had a 14-day end date for 1 (Resident #1) of 5 sampled residents reviewed for psychotropic medications.

Inspectors wroteBased on interview, observation, and record review, the facility failed to meet this requirement when one of three sampled residents (Resident 1) received no documented bathing between 12/8/23 and 12/15/23 (seven days). This potentially contributed to Resident 1's several areas of documented skin redness and breakdown.

Inspectors wroteBased on interview and record review, the facility failed to implement their Skin Integrity Management policy and procedure when two out of two sampled residents (Resident 1 and Resident 2), had wounds and the facility had not followed procedures as outlined in their policy. 1a. Resident 1 had a chronic (occurring for a long time, more than three months), infected chest wound and there were no wound measurements (written measurement that described the length, width, and depth of the wound) documented in the medical record; and 1b. Resident 1 had a chronic, infected chest wound and two weekly wound assessments did not include the effectiveness of the current treatment when the Licensed Nurse (LN) inaccurately documented there was no wound; and 1c. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to respond timely to resident's request and treat resident with dignity and respect for one of three sampled residents (Resident 1). This failure resulted in Resident 1 lying in feces for a long period of time and upsetting Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy and the physician orders to prevent Pressure Ulcers/Injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device), revise individualized care plan and provide treatment for the pressure injury wound for one of three sampled (Resident 1). These failures could have the potential to delay the wound healing and increased the risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy and treat four residents (two confidential residents and Resident's 6 and 39) with dignity and respect. This caused the residents to feel humiliation, embarrassment, a loss of dignity, and frustration while using the toilet.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from accidents and hazards when: 1. Door closures were not maintained or closing properly. This had the potential for residents to be injured in doorways if not prepared for the swift door closures. 2. Smoking area had multiple cigarette butts near dry leaves in 2 locations. This had the potential to result in a fire close to the building. 3. Resident 4 had more than 30 falls in the last 12 months and Resident 211 had five unwitnessed falls in a two month period. This had the potential to place these resident at risk for continued falls and serious life threatening injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet residents shower needs. This had the potential for residents to not receive showers as scheduled or requested which could negatively affect their physical and emotional well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safe and effective use of medication when the policy for Medication Storage was not implemented for two sampled Residents (11 and 410) as evidence by the following: 1. Insulin Pen, (a device for insulin administration; insulin is injected to control blood sugar for patients with uncontrolled blood sugar), for Resident 11, remained available for use, after the expiration date 5/13/2021. 2. Eye drops (a lubricant used to keep the eye moist also known as artificial tears) for Resident 410, also had the expiration date as 5/13/2021, and it was available for use. This failure resulted in putting both Resident (11 and 410) at increased risk of harm from receiving expired and potentially contaminated or ineffective medications.

Inspectors wroteBased on interview and record review, the facility failed to identify the irregularity of significant medication error that continued for five months for one out of seven sampled residents (Resident 56). Pantoprazole 40 mg was administered instead of 20 mg to Resident 56 from 12/27/2020 to 5/26/2021 (refer to F 760). There was no documented evidence that the error was not identified or reported. This failure resulted in Resident 56 receiving double the dose of pantoprazole for more than five months.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of seven sampled residents (Resident 56) was free from unnecessary drugs. Resident 56 received an excessive dose of medication intended to reduce stomach acid (pantoprazole). This failure resulted in Resident 56 was administered double the ordered does (40 milligrams instead of 20) of pantoprazole for five months and put this Resident at increased risk of harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of seven residents (Resident 30) is free from unnecessary psychotropic drug, which affects brain activities associated with mental processes and behavior . Resident 30 continued to receive Lexapro (a medication used for depression) for six months, in the absence of clinical indication to do so. This failure resulted in Resident 30 receiving unnecessary psychotropic medication and put the resident at increased risk for drug related side effects and potential harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent significant medication error for five months, when one out of seven sampled residents (Resident 56) was given pantoprazole 40 mg /tab without a physician order. (pantoprazole reduces the amount of acid the stomach makes. It's used for heartburn, acid reflux.) This failure resulted in Resident 56 having been given the wrong dose of pantoprazole from 12/27/2020 to 5/26/2021, and put the resident at increased risk of potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility's Quality Assessment and Assurance committee (QAA) failed to identify and implement plans of actions to correct deficiencies when: 1. Fall intervention strategies to reduce injuries and falls were not implemented. Refer to F 689. 2. There was not sufficient staffing to provide activities of daily living (showers) and supervision to prevent accidents and hazards. Refer to F 725. 3. Infection Control policies did not meet current standards and staff had not implemented the procedures. Refer to F 880. 4. Building maintenance for air conditioning, shower room water and room temperatures, and monitoring door closure issues was not done. Refer to F 689, F 921. These failures had the potential to put all residents at risk for injury and to be exposed to infectious disease.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program that provided a safe and sanitary environment for residents and staff when: 1. Staff did not follow facility hand hygiene and isolation policies/procedures while providing care to Resident 260 who was on contact precautions. 2. Resident 260, who was being ruled out for C.diff (Clostridioides difficile, a germ that causes severe diarrhea and inflammation of the colon) infection, was not cohorted in a manner to prevent risk of spread. 3. N95 respirator fit testing was not completed for five of six sampled staff. 4. Facility infection control plan and infection control policies/procedures were not reviewed annually as required. 5. Terminal cleaning of room previously occupied by Resident 260, was completed while occupied by Resident 260's former roommate Resident 21. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe and sanitary environment for residents when: 1. Door closures were not maintained and closed abruptly. This failure resulted in two fractured fingers for Resident 29). 2. Air conditioning unit were not functioning in the resident dining room. This failure resulted in above normal (over 81 degrees F, Fahrenheit) room temperatures in the dining room. 3. Shower room water temperatures and shower room air temperatures were not maintained at a comfortable temperature. This failure resulted in residents refusing showers due to cold water and room air temperatures in shower rooms [ROOM NUMBERS]; 4. Shower heads were not maintained in an operable condition. This failure had the potential to contribute to residents refusing showers. 5. Maintain clean and sanitary shower rooms/stalls. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide rehabilitative care services for one resident (Resident 33). This failure had the potential to cause Resident 33 to lose strength and balance for walking, which could have led to a loss of independence and increased risk for falls.

Inspectors wroteBased on interview and record review, the facility failed to provide residents with personal hygiene and grooming when: 1. Three residents (Residents 15, 17, and 49) refused to shower because too cold. 2. One resident (Resident 46) had dry, scaly skin and jagged, dirty fingernails. This failure had the potential to have caused the residents to experience discomfort and anxiety from poor hygiene and fear of the cold, as well as to promote the risk of infection due to the spread of bacteria from beneath the fingernails.