Childrens Hc Org No Ca Saratoga Pediatric Subacute

Inspectors wroteBased on interview, and record review, the facility failed to maintain and meet current standards of nursing practice when, the medication was not administered according to the physician's order for one of two residents (Resident 1). This failure could potentially result in complications of the residents' medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement specific, individualized and resident-centered care plans for the side or bed rails (adjustable rigid bars attached to the side of a bed) of twelve, (Residents 16, 19, 4, 27, 5, 1, 29, 6, 32, 14, 24 and 12), out of thirty-three residents in the facility, when these twelve residents who used side rails did not have specific, individualized and resident-centered care plans for their side rails. These failures had the potential for these residents to be at risk, for not being properly monitored and provided with the appropriate interventions with regards to their use of side rails, which could compromise their safety and quality care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' environment remained free of accident hazards to prevent avoidable accidents, in order to provide safe environment for residents when there were missing logs in their laundry dryer lint tray cleaning monitoring sheet for February 2026. These failures had the potential for causing fire accident that might result in injury and harm to the thirty-three residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 14.29% when 4 medication errors out of 28 opportunities were observed during medication pass for two of ten residents (Residents 8 and Resident 16). These failures had the potential to compromise the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an expired medication was removed from one of four medication carts inspected for one of thirteen sampled residents (Resident 3); and, three expired control solutions (liquid solution used to verify that a blood sugar machine and test strips are working accurately together) were not removed from an active use supply area of a medication room. These failures had the potential for the residents to receive expired medication and/or be inaccurately assessed for blood sugar.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an allegation of abuse involving one of two sampled residents (Resident 1) to the State Survey Agency. This failure had the potential to delay investigations and compromise Resident 1's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their Bed/Side Rails policy for 20 of 22 residents (1, 2, 3, 4, 5, 6, 9, 11, 14, 16, 18, 23, 24, 25, 27, 181, 182, 184, 330, and 331) when they did not attempt alternative measures prior to applying bed side rails. This failure had the potential to place the residents at risk of entrapment and serious injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when: 1. Food was kept beyond their open and expiration dates, 2. Temperature logs for two refrigeration units had missing entries, 3. Five opened spice containers were without expiration dates, 4. Three cutting boards had deep cut marks on their surface, 5. Five red onions and four yellow onions were moldy, six potatoes were soft and wrinkled, and 6. A fan had dark particles on its fan blades and grills. These failures had the potential to cause food-borne illness for residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when the filters of oxygen concentrators were dusty for five of 13 residents (3, 23, 25, 183, and 184). This failure had the potential to spread infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy by failing to obtain background checks for one of three certified nursing assistants (CNA C), when CNA C was hired without a background check. This failure had the potential to put the residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nursing staff administered a medication accurately according to the manufacturer's specifications for one of 12 sampled residents (Resident 331), when Resident 331's Lansoprazole (drug used to reduce stomach acid) Oral Disintegrating Tablet (ODT, fast-melting tablet that dissolves quickly in saliva/water) 30 milligrams (mg, unit of mass measurement) was crushed before administration, contrary to the manufacturer's guidelines. This failure had the potential to reduce medication efficacy for Resident 331.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a multi-dose medication was labeled with an open date after opening, and not stored beyond its discarding date. This failure had the potential for residents to receive expired, contaminated, or deteriorated medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed when: 1. Housekeeper (HK E) did not change gloves and did not perform hand hygiene; 2. Resident 4's oxygen nasal cannula tubing (a device used to deliver supplemental oxygen or airflow) was touching the bedside table; 3. Resident 4's oxygen connector was exposed and touching the side rail; 4. Medication cart garbage next to the Resident 4's bedside table was over flowing; 5. Certified nursing assistant M (CNA M) did not change gloves and did not perform hand hygiene; 6. Ambu bags were not stored inside the equipment containers. These failures had the potential to spread infection in the facility. 1. During an observation on 1/21/2020 at 1:12 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy when a skin discoloration of unknown origin was not investigated to rule out abuse. This failure placed the resident at risk for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow facility policy related to accountability and documentation of controlled substances (drugs with high potential for abuse and addiction) for four out of six sampled residents when: 1. For Resident 21, quantity of a controlled substance received from the pharmacy does not match what was documented. 2. For Resident 29, a controlled substance was delivered by a licensed nurse to a general acute hospital without obtaining permission to leave and missing documentation related to physician's order. 3. For Resident 1, a controlled substance was not properly documented. 4. For Resident 30, 4.6ml (milliliters, a unit of measurement) of a controlled substance was not accounted for and not reported immediately to responsible supervisor. These failures had a potential for diversion of highly controlled substances.

Inspectors wroteBased on observation, interview, and record review, the facility had 8% medication error rate when two medication errors out of 25 opportunities were observed during medication pass. This failure resulted in Resident 30 not getting his medications as ordered by the physician.

Inspectors wrote2. During a breathing treatment observation on 1/21/2020 at 5:41 p.m. with respiratory therapist C (RT C), RT C had a medication room key to get Resident 4's respiratory medications inside the medication room without the facility licensed nurse present. During an interview on 1/21/2020 at 6:04 p.m. with RT C, RT C acknowledged the above observation. RT C further stated she had her own key to enter the medication room without the facility licensed staff present. During a breathing treatment observation on 1/21/2020 at 4:40 p.m. with RT F, RT F had a medication room key to get Resident 12' s respiratory medications inside the medication room without the facility licensed nurse present. During an interview on 1/21/2020 at 5:31 p.m. with RT F, RT F confirmed the above observation. RT F stated he had his own key to go inside the medication room without facility licensed staff present. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure aerosol disinfectant was stored properly when the chemical disinfectant was found at the bed side of Resident 4. This failure had the potential for Resident 4 to access the hazardous chemical and jeopardize his health and safety.