Country Crest Post-Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food safety requirements regarding the preservation of a sanitary kitchen environment in addition to appropriate storage and labeling of foods when the main kitchen was observed to have a build up of grime and webbing on pipes under counters, mineral and corrosive (something that causes gradual harm due to a chemical reaction) buildup on pipes and draining apparatuses, dirt buildup on flooring and air gap drains, grease and grime on the hood over the stove, breadcrumb buildup in the toaster, dirt buildup on the filters and plastic of a portable cooler unit, a large unlabeled brisket thawing in the refrigeration unit, expired Yoplait yogurt in the refrigeration unit, a container of red gelatin dessert unlabeled in the refrigeration unit, and an inadequately covered cardboard box of sliced mushrooms in the [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean homelike environment when two of three shower rooms were found to be less than adequately maintained when the laminate on counter tops was chipped, paint was chipped and not adhered to the walls above and around the shower stalls, flooring was in disrepair in front of the shower stalls, by the door, as well as within the shower stalls. This failure had the potential to result in disease transmission, with increasing health complications and overall wellbeing issues to those residents utilizing the common space. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that it remained free from (potential) accidents and hazards when two of three shower rooms were observed to have a hole in the floor of one shower room, and an open box on the wall appearing to be a temperature control apparatus with exposed wires and sharp edges in the second shower room. This failure had the potential to result in physical injury leading to psychological trauma and health decline for residents utilizing the common space. During a review of the facility's policy and procedure titled, Hazardous Areas, Devices and Equipment, dated Revised July 2017, the policy indicated, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide physical therapy (PT) services as indicated on the evaluation for five out of five sampled residents (Resident 1, 9, 13, 34, and 41) when:Residents 1, 34, and 41 were not provided with PT five times a week. Residents 9 and 13 were not provided with PT three times a week. This had the potential to result in a decline in physical function and physical ability and prevented Resident 1, 9, 13, 34, and 41 from reaching their full potential and causing health complications and emotional dysfunction. A review of Resident 1's clinical record indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included, muscle weakness, unsteady on feet, dementia (loss of memory), and anxiety (fear of unknown). [...]

Inspectors wroteBased on interview and record review, the facility failed to implement an individualized patient-centered care plan for two of 15 sampled residents (Resident 9 and 41) when:Certified Nurse Assistant (CNA 3) transferred Resident 9 to bed without assistance and Resident 9 fell to the floor. CNA 3 ambulated Resident 41 without assistance and Resident 41 fell to the floor causing a skin tear. These failures resulted in Resident 9 and Resident 41 to fall had had the potential to cause broken bones. 1. A review of Resident 9's clinical record indicated, Resident 9 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnosis that included, muscle weakness, unsteady on feet, and dementia (loss of memory). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards were followed when nursing staff failed to wear appropriate personal protective equipment (PPE) while handling hazardous medication (medications that can cause serious effects including cancer, organ toxicity, fertility problems, genetic damage, and birth defects if not handled appropriately). This failure had the potential to result in unwanted exposure to hazardous medications leading to health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability of controlled medications (those with high potential for abuse or addiction) when random controlled medication audits for one out of four residents (Resident 16) did not reconcile. Two controlled medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but were not accurately documented on the Medication Administration Record (MAR) to indicate they were administered to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of five sampled residents (Resident 9 and Resident 29) were free of significant medication errors when both residents received latanoprost eye drops (a medication to treat glaucoma and ocular hypertension) multiple times (doses) past the expiration date. This failure had the potential for ineffective use of the latanoprost eye drops, placing the residents at risk for worsening of their medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure opened multi-dose medications and biologicals were dated with an open and discard date to ensure they were not used beyond the discard date, and expired medications were not available for resident use. This failure had the potential for residents to receive medications or biologicals with unsafe and reduced potency from being used past their discard date, and incorrect medications from inadequate labeling.

Inspectors wroteBased on interviews, and record review, the facility failed to provide needed care and service for one of three sampled residents (Resident 1), when:1. A change in condition was not recorded and reported to the Medical Director (MD) when Resident 1 experienced a decrease in the frequency of her daily brief (type of adult disposable underwear) changes, which was a significant indicator of decreased urine output. 2. A laboratory blood test (labs - the process of analyzing a blood sample to measure specific substances) order placed by the MD on [DATE], was not fulfilled, resulting in Resident 1's lab not being drawn as instructed. These failures led to Resident 1 not receiving appropriate medical assessments and treatment, ultimately resulting in her death on [DATE].

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) received wound preventative measures as ordered to prevent skin breakdown, promote circulation, and provide pressure relief. This failure resulted in Resident 1 sustaining a stage 2 pressure ulcer (partial-thickness skin loss, where the epidermis (outer layer) and part of the dermis (second layer) are damaged caused by prolonged pressure) to their coccyx (tailbone), which had the potential to lead to complications including pain, discomfort, and infection.

Inspectors wroteBased on interview and record review, the facility failed to notify the Medical Director (MD) for one of three sampled residents (Resident 1), when there was a need to alter Resident 1's healthcare decision maker as Resident 1 was still listed as the decision maker. Resident 1 had a St. Louis University Mental Status (SLUMS) examination (a cognitive screening test designed to detect the early signs of mild cognitive impairment and dementia) done on 7/22/24, and had a score of 3 out of 30, indicating that Resident 1 was cognitively impaired. This failure resulted in the facility continuing indicating that Resident 1 Has the capacity to make and understand decisions , and only notified Resident 1 when there was an alleged abuse allegation.

Inspectors wroteBased on interview and record review, the facility failed to report an abuse allegation for one of three sampled residents (Resident 1) when Resident 1 informed Certified Nursing Assistant (CNA) A that a male staff was Really rough when getting her [Resident 1] in & out of bed, grabbed her really hard, and wanted to hurt her on 10/24/24. This failure had the potential to result in psychosocial and emotional harm for Resident 1 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure social services met the needs for two of three residents (Resident 1, 2) when: 1. The Social Service Director did not investigate and reported to the authorities after Resident 1 informed the Certified Nursing Assistant (CNA) B of an allegation of abuse on 10/24/24. This failure had the potential to result in psychosocial and emotional harm for Resident 1 and had the potential to place all the residents at risk for undetected/unreported elder neglect or abuse. 2. The Social Service Director failed to ensure the Behavior Management Committee address the appropriateness of the use of the psychotropic medication when Resident 2 was prescribed with PRN Lorazepam (brand name: Ativan - used to relive anxiety) for extended time period without the rationale. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure safe use of psychotropic medications (medication that alters mood, behavior, and cognition) for one of three sampled residents (Resident 2) when Resident 2 was prescribed with Lorazepam (brand name: Ativan - used to relive anxiety) for extended time period without the rationale. This failure could contribute to unsafe use of psychotropic medications that could have placed residents at risk for adverse consequences.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure sanitary preparation and service of meals. Specifically, the facility failed to practice proper hand hygiene and glove use during food preparation, and the facility failed to hold foods at safe temperatures during meal service. This had the potential to affect all residents who received meals from the facility's kitchen.

Inspectors wroteBased on observation, interview, facility policy review, and review of the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure 1 of 1 dumpster was closed to prevent the potential for vermin and pest attraction. This had the potential to affect all 56 residents that resided in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure oxygen was administered appropriately for 3 (Residents #204, #17, and #11) of 4 residents reviewed for respiratory care. Specifically, the facility failed to ensure Resident #204 and Resident #17 received oxygen at their prescribed flow rates and failed to ensure the humidifier bottle on Resident #11's oxygen concentrator was functioning properly.

Inspectors wroteBased on observation, interview, record review, facility document review, and facility policy review, the facility failed to ensure an effective infection prevention and control program was followed and maintained for 1 (Resident #38) of 1 resident reviewed for urinary catheters and 3 (Residents #37, #17, and #204) of 4 residents reviewed for respiratory care. Specifically, Resident #38's urinary catheter bag was observed on the ground or floor, and respiratory equipment was inappropriately stored to prevent infections for Residents #37, #17, and #204.

Inspectors wroteBased on observation, interview, record review, and review of the Centers for Medicare and Medicaid Services [CMS] Long-Term Care Facility Resident Assessment Instrument [RAI] 3.0 User's Manual, the facility failed to ensure oxygen use was accurately coded on the Minimum Data Set (MDS) assessment for 2 (Resident #17 and Resident #11) of 4 residents reviewed for respiratory services.

Inspectors wroteBased on interview, record review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I PASRR accurately reflected the presence of a serious diagnosed mental disorder and the use of prescribed psychotropic medication for 1 (Resident #30) of 4 residents reviewed for PASRR requirements.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and a comprehensive person-centered care plan for 1 (Resident #34) of 4 sampled residents who had cardiac pacemakers. Specifically, the facility failed to develop a care plan for the care and treatment of Resident #34's cardiac pacemaker.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure pharmacy recommendations were addressed for 1 (Resident #40) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure PRN (pro re nata, as needed) psychotropic medication use was limited to 14 days for 1 (Resident #7) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the medication error rate was less than 5 percent (%). The facility had 2 errors out of 36 total opportunities, resulting in a medication error rate of 5.55 %, affecting 2 (Resident #6 and Resident #34) of 5 residents observed during medication administration.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to maintain a complete medical record for 1 (Resident #4) of 4 residents reviewed who had a cardiac pacemaker. Specifically, the facility failed to ensure Resident #4's medical record contained information regarding the model and/or serial number and the implant date for the resident's cardiac pacemaker.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the daily staffing postings were updated every shift for 24 days from 09/01/2024 through 09/24/2024. This had the potential to affect all 56 residents that resided in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report injury of unknown origin for one resident (Resident 1) out of three sampled residents reviewed for abuse within 2 hours, to the California Department of Public Health (CDPH). This failure had the potential to delay investigation and interventions to prevent abuse to other residents in the facility.

Inspectors wroteBased on interview, record review and observation, this regulation was not met when two vinegar bottles, one molasses bottle, and a 20 gallon jug of unlabled cooking oil, and five bags of bread and rolls were observed not to have expiration, open dates, or use-by dates. This resulted in the potential for foodborne illness and lack of palatability of the affected food, for all residents.

Inspectors wroteBased on dietetic services observations, dietary staff interview and departmental document review, the Registered Dietitian (RD) and/or the Dietary Services Supervisor (DSS) failed to ensure: 1) Vegetarian menus were in place and followed. 2) Timely and effective communication and monitoring system was in place between the facility kitchen and the contract kitchen regarding resident diet orders and food allergies. These failures had the potential to result in nutritionally inadequate meals, and the potential to promote decline in medical and nutritional status as well as quality of life for residents who received food from the facility food services.

Inspectors wroteBased on resident interviews, meal delivery observations and departmental document review the facility failed to ensure meals were presented at a temperature that met the individual preferences of two Residents (Residents 36 and 246). Failure to ensure meals are prepared and delivered in a manner that meets residents needs may result in decreased food intake, resulting in weight loss further compromising medical status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food were stored, prepared, distributed and maintained in safe and sanitary condition in their contracted kitchen when: 1. a. The facility kitchen staff were not following the departmental dress code. b. Internal bin of the ice machine had an area with pink, clear slimy appearing material. c. The kitchen areas and equipment were not clean. 2. a. Refrigerated food were not labeled, dated, monitored and raw foods were not separated from ready-to-eat foods. b. Potentially hazardous foods (PHF) were not at safe temperatures below 41°F. These failures had the potential for the spread of infection and foodborne illness to occur to residents.

Inspectors wrote2) A review of Resident 7's record indicated she was admitted to the facility on [DATE] with diagnoses that included dementia and muscle weakness. MDS, dated [DATE], indicated Resident 7 had severe cognitive impairment (unable to think and reason), total dependence for activities of daily living (ADLs), and required two person assistance for bed mobility (how a resident moves to and from lying position, turns side to side, and positions body while in bed), transfers (how a resident moves between surfaces including to or from: bed, chair, wheelchair, standing position), and toilet use. Resident 7's range of motion was impaired on both sides of her upper and lower extremities, and used a wheelchair for mobility. A review of Resident 7's Nurses Progress Note, dated 10/22/2021 at 6:21 AM by Licensed Nurse (LN) F, indicated Resident 7 had a witnessed fall. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure contracted kitchen staff were able to verbalize or demonstrate their competence to carry out the responsibilities of the food and nutrition services when: 1) Staff did not properly complete the food cooling process to ensure food safety. 2) Staff signed off on cleaning schedules, indicating 100% of daily cleaning assignments were completed when equipment was not clean. 3) Staff did not follow standardized recipes. These failures had the potential to result in foodborne illness, decreased nutritional status, and medical decline for residents consuming food prepared in the contract kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure menus were in place and followed when: 1. A vegetarian menu was not used or followed, and the nutritional adequacy of vegetarian meals served to two residents (Residents 14, 42) since admission was unknown. 2. Menus were not followed for 10 of 10 residents (Residents 3, 17, 18, 28, 30, 34, 245, 251, 254, 397) on mechanical soft diets. 3. Portions were not served according to the menu for six of 43 residents (Residents 4, 10, 12, 19, 38 and 397). 4. Menus for therapeutic diets were not followed for three residents (Residents 22, 24 and 28). These failures created the potential for residents to receive food that did not comply with the physician ordered diet, did not meet resident nutritional needs, and had the potential to compromise residents' medical status, nutritional status, and quality of life.

Inspectors wroteBased on dietetic services observations, dietary staff interview and departmental document review the facility failed to ensure pureed foods for seven residents (Residents 7, 8, 32, 40, 252, 244 and 396) were prepared in accordance with standards of practice and departmental policies. Failure to ensure meal preparations were in accordance departmental procedures may result in decreased meal intake compromising the nutritional status of residents.

Inspectors wroteBased on interview and record review, the Administrator (ADMIN) failed to provide and administer oversight and use its resources effectively when: 1. Infection control program for soiled resident laundry was not implemented, staff training, to ensure their policy and procedures followed Center of Disease Control (CDC) infection control standards. This failure resulted in resident clothing not being clean and sanitary and had the potential to spread disease and infection throughout the facility. Refer to F 880 and F 867 2. Dietary services did not follow national standards and guidelines for kitchen cleanliness, food temperatures,storage and nutritional needs. Refer to F 803, F804, F 805 and F 812. This commulative failures resulted in a potential for spread of disease and infection and dietary needs of residents' not to be met.

Inspectors wroteBased on observation, interview and record review, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify and implement plans of action to correct deficiencies when: 1. Laundry services for residents did not meet standards for sanitation and infection control. This failure resulted in resident clothing not being cleaned and sanitary and had potential for the spread of diseases and infection throughout the facility. Refer to F880. 2. Dietary services did not meet the nutritional and palatability needs of residents. These failures created the potential for residents to receive food that did not comply with the physician ordered diet, did not meet resident nutritional needs, and had the potential to compromise residents' medical status, nutritional status, and quality of life. Refer to F803, F804, and F805. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Center of Disease Control (CDC) infection control standards for residents' soiled laundry were implemented. This failure resulted in residents' clothing not being cleaned and sanitary and had the potential to spread disease and infection throughout the facility.

Inspectors wrote4) During an observation on nursing unit C, on 01/10/2022 at 11:10 AM, it was noted the shower room sink had a small clump of gray hair that had not been cleaned out. In a concurrent observation and interview with Certified Nursing Assistant (CNA) J, on 01/10/2022 at 11:16 AM, CNA J stated staff rinsed out used wash cloths in sink but they didn't wash resident's hair in the sink. CNA J confirmed there was a clump of gray hair in sink drain in the shower room on nursing unit C. 5) Review of a facility policy titled, Medication Administration, revised 02/2013, indicated that, The nurse or authorized staff member on duty ensures equipment and supplies relating to medication storage and use are clean and orderly. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) D was competent to provide safety measures during resident care, when Resident 7 rolled off the bed. This failure resulted in Resident 7 sustaining injuries that required a trip to emergency department services for evaluation and treatment.