Foothill Regional Medical Center D/P SNF

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive care plan was developed to reflect the individual care needs for five of nine final sampled residents (Residents 1, 5, 6, 9, and 15). * The facility failed to develop a care plan for Resident 15's use of lorazepam (antianxiety medication) and diazepam (antianxiety medication). * The facility failed to develop a care plan for Resident 1's GT feeding and use of insulin lispro (medication to lower blood sugar). * The facility failed to develop a care plan to address the use of GJ tube feeding for Resident 5. * The facility failed to develop a care plan for Resident 6's use of the duloxetine (antidepressant medication) and trazadone (antidepressant medication). * The facility failed to develop a care plan for Resident 9's use and management of the GT. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The facility failed to ensure food was properly labeled in the refrigerator. * The facility failed to ensure items in the kitchen were discarded after the use-by/expiration date. * The facility failed to ensure the kitchen equipment was stored or kept in sanitary conditions. * The facility failed to ensure the kitchen equipment was air-dried. * The facility failed to ensure the microwave was kept in clean and sanitary condition. * The facility failed to ensure the food preparation sinks had an air gap. These failures had the potential for exposure to food-borne illnesses for a medically vulnerable population.

Inspectors wroteBased on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection prevention control program and practices designed to provide a safe and sanitary environment to help prevent the transmission of communicable diseases and infections. * The facility failed to maintain an accurate infection control surveillance program for January 2025. The facility conducted surveillance only on the residents who exhibited signs and symptoms of an infection and were prescribed antimicrobial medications. The facility failed to ensure the residents exhibited signs and symptoms of an infection but were not prescribed antimicrobial medications were included in the facility's infection control surveillance log, and in the monthly infection surveillance report. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure staff provided care and promoted dignity and respect for two of nine final sampled residents (Residents 10 and 18). * The facility failed to ensure the privacy curtain was drawn for Resident 10 when CNA 1 was changing and providing care to the resident. * The facility failed to ensure the privacy curtain was drawn for Resident 18 when RT 1 was suctioning the resident. These failures had the potential to negatively impact the residents' feelings of self-worth and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to fully inform the resident or responsible party and obtain a completed informed consent prior to the use of the psychotropic medications for one of five final sampled residents (Resident 15) reviewed for unnecessary psychotropic medications. *The facility failed to ensure the informed consent was obtained from Resident 15's representative prior to the use of lorazepam (antianxiety medication) and diazepam (antianxiety medication). This failure had the potential for Resident 15 and their responsible party to be unaware of the risks associated with psychotropic medications and the potential side effects.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Residents 6 and 15) reviewed for unnecessary medications were free from unnecessary psychotropic medications. * The facility failed to ensure the physician's order for the duloxetine (antidepressant medication) and trazodone (antidepressant medication) had the specific behavior manifestations for Resident 6. Additionally, the facility failed to ensure Resident 6 was monitored for the specific behaviors and side effects/adverse reactions related to the use of the duloxetine and trazodone medications. * The facility failed to ensure Resident 15 was monitored for the specific behaviors and side effects/adverse reactions related to the use of the lorazepam (antianxiety medication) and diazepam (antianxiety medication). [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate care and services for the use of GT for one of nine final sampled residents (Resident 9) reviewed for tube feedings. * The facility failed to ensure Resident 9's HOB was elevated 30 degrees or greater during the enteral feeding to reduce the risk of aspiration. These failures posed the risk for complications related to use of the GT for Resident 9.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of five sampled residents (Resident 6) reviewed for unnecessary medications was free from the unnecessary medications. * The facility failed to ensure Resident 6 was monitored for signs and symptoms of bleeding related to the use of the enoxaparin (anticoagulant) therapy. This failure had the potential for Resident 6 to receive unnecessary medications and develop significant adverse effects.

Inspectors wroteBased on interview, facility document review, medical record review and facility P&P review, the facility failed to ensure the antibiotic stewardship program monitored and addressed the use of the antibiotics for one of nine final sampled residents (Resident 10) and one nonsampled resident (Resident 16) . * The facility failed to monitor and address the use of antibiotics when the resident's condition did not meet McGeer's criteria. This failure had the potential for antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.

Inspectors wroteBased on interview and facility document review, the facility failed to ensure the Facility Assessment was complete. * The facility failed to ensure the Facility Assessment addressed or included the following: active involvement of required individuals in developing facility assessment, resources necessary to care for residents including weekends, include a plan to maximize recruitment and retention of direct care staff and include a contingency plan for staffing needs. This failure had the potential not to meet the residents' care needs if the assessed population's needs and resources were not comprehensively identified and addressed.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the POLST for one of nine final sampled residents (Resident 1) was completed. * Resident 1's POLST was incomplete. This failure had the potential for Resident 1's care needs to not be met as their medical information was not complete.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented. * The facility failed to record all the residents with infection on the facility's infection surveillance tool. The facility's infection surveillance tool did not include all the residents identified with infections. Only the residents with positive culture results were identified as having infection and were listed on the surveillance list. * The facility failed to ensure Resident 8's water pitcher was clean. * LVN 1 failed to disinfect the stethoscope after use on Resident 9 and prior to exiting the room. * LVN 4 failed to disinfect the stethoscope after use on Resident 12 and prior to exiting the room; [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of nine final sampled residents (Residents 7 and 18). * The facility failed to develop a comprehensive person-centered care plan to address Resident 18's nutritional oral gratification and GT feeding. In addition, the facility failed to develop a comprehensive care plan for the use of the abdominal binder. * The facility failed to develop a comprehensive person-centered care plan to address Resident 7's GT feeding. These failures had the potential risk of not providing appropriate, consistent, and individualized care to these residents.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the treatment was provided to two of nine final sampled residents (Residents 4 and 12). * The facility failed to assess and check the skin of Residents 4 and 12 every two hours when the splint device was applied as ordered by the physician. In addition, the plans of care to address the function and mobility of Residents 4 and 12 were not included in the interventions for skin assessments every two hours when the splint device was applied. These failures had the potential to affect the residents well being while wearing the splint device.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure appropriate care and services for the use of a GT for two of nine final sampled residents (Residents 7 and 12) and two nonsampled residents (Residents 1 and 9). * The facility failed to ensure LVN 1 elevated Resident 9's HOB at a 30 degree angle or above prior to the administration of medication via the GT, to reduce the risk of aspiration. * The facility failed to ensure LVN 3 elevated Resident 12's HOB at a 30 degree angle or above prior to the administration of the medication via the GT, to reduce the risk of aspiration. * The facility failed to ensure Resident 1's HOB was elevated at a 30 degree angle or above during the enteral feeding via the GT. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to obtain the informed consent for the use of side rails for one of three final sampled residents (Resident 11) reviewed for side rails. This failure posed the risk for Resident 11 and/or his representative to not be informed of his care and the risks for the padded bilateral upper and lower siderails.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate administration and storage of the medications as evidenced by: * The facility's medication error rate was 3.85%. One of four licensed nurses (LVN 4) who were observed during the medication administration was found to have an error. LVN 4 failed to administer the complete dose of one of Resident 3's medications when significant residual of the medication was observed in the medication cup after administering the multivitamin (supplement) via GT to Resident 3. * The facility failed to ensure the electronic MAR for Resident 3 was not signed prior to the medication administration. [...]

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of nine final sampled residents (Resident 4) were free from the unnecessary medications. * The facility failed to ensure to document the monitoring of seizure activities and side effects related to Resident 4's use of clobazam, clonazepam, diazepam, lacosamide, lamotrigine, and levetiracetam (anticonvulsant medications to prevent seizure). This failure had the potential for Resident 4 to receive unnecessary medications and develop significant adverse effects, and risk for adverse effects from prolonged used of medications.

Inspectors wroteBased on interview, and medical record review, the facility failed to ensure one of five final sampled residents (Resident 2) reviewed for unnecessary medications was free from the unnecessary psychotropic medication when: * The facility failed to monitor the behaviors specific to the use of clonidine (antihypertensive and sedative medication) for Resident 2. * The facility failed to ensure the informed consent was obtained from the resident representative for the use of the psychotropic medication (clonidine) when the route of administration, dose, and targeted behaviors were changed for Resident 2. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the residents' medications were stored and labeled properly. * The facility failed to ensure the medications were stored inside a locked medication cart and were not left unattended by the licensed nurse. * Resident 12's simethicone (antiflatulence) medication was not labeled with the opened date. These failures had the potential for medication diversion and resident exposure to the expired medications with questionable potency and efficacy.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food safety and sanitation guidelines were followed when: * The facility failed to ensure the kitchen equipment was maintained in a sanitary condition. * The facility failed to ensure the food items was properly stored and maintained. These failures had the potential to result in foodborne illnesses for the residents receiving kitchen services in the facility.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the COVID-19 immunization was offered and administered to three of five sampled residents (two final sampled residents, Residents 17 and 6; and one nonsampled resident (Resident 1) reviewed for COVID-19 immunization. This failure placed the residents at risk to acquire COVID-19 infection.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the dish machine was repaired in a timely manner to ensure the dish machine final water temperature reached a minimum of 180 degrees Fahrenheit (F) as per manufacturer instruction. This failure had the potential to cause foodborne illness for residents using dishes that were not properly sanitized.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify one of two final sampled residents (Resident 8) reviewed for hospitalization of his rights to a bed hold (holding or reserving a resident's bed while the resident in the acute care hospital) policy upon the transfer to the acute care facility in writing. This failure had the potential for the resident and/or his representative to be unaware of their rights to request a bed hold upon transfer.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the quarterly MDS assessment was completed for one final sampled resident (Resident 6) and one nonsampled Resident (Resident 13). This had the potential to not provide appropriate care when there was no MDS assessment information available.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the MDS was coded accurately for one of nine final sampled residents (Resident 6). This failure had the potential for the resident's negative health outcome as the information was not accurate.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage and refuse were properly stored in one of one garbage dumpster and compactor. Litter, and dark liquid collected with odor was observed under and around the garbage dumpster and compactor. This failure had the potential to harbor pests or rodents which carry diseases.

Inspectors wroteBased on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of two sampled residents (Resident 1). * The facility failed to implement their P&P to conduct an hourly rounding, neurological, skin, and body assessments for Resident 1 after she had sustained a fall on 11/2/24. * The facility failed to thoroughly investigate the fall incident for Resident 1. These failures had the potential to negatively affect the resident's health condition and well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the medical record for one of two sampled residents (Resident 1) was complete and accurate. * The facility failed to accurately document Resident 1's Fall Risk Assessment post fall on 11/7, 11/11, and 11/17/24. This failure had the potential for the resident's care needs not being met.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to ensure the resident's Physician Orders for Life-Sustaining Treatment (POLST) was obtained and maintained in the medical record for one of 12 final sampled residents (Resident 22). This failure had the potential for the resident's decisions regarding his healthcare and treatment options to not be honored.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 12 final sampled residents (Residents 8 and 24) were free from the physical restraints. * The facility failed to conduct an assessment, obtain an informed consent and a physician's order, and implement the least restrictive interventions prior to applying the seat belt and chest strap restraints for Residents 8 and 24 when the residents were up in the wheelchair. In addition, the facility failed to monitor and document the use of seat belt and chest straps restraints in the wheelchair. These failures posed the risk of compromising the residents' independence and psychosocial well-being.

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to notify the Office of the State Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) of Resident 25's discharge to another SNF. This failure had the potential for the Ombudsman not knowing about the resident's discharge to another SNF.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the environment was free from accident hazards for two of 12 final sampled residents (Residents 3 and 16). This failure had the potential to negatively affect the residents' well-being and increased the risk of accidents or injuries to the residents.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure three of 12 final sampled residents (Residents 13, 14, and 24) remained free from accident hazards associated with the use of elevated side rails. * The facility failed to assess Residents 13, 14, and 24 for the risk of entrapment from elevated side rails. This failure had the potential to place the residents at risk for entrapment and serious injury.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to ensure one of 12 final sampled residents (Resident 24) was free from the unnecessary psychotropic medications. * The facility failed to ensure the physician's order for the quetiapine medication (a medication use to treat symptoms of schizophrenia or bipolar disorder) had a behavior indication for it's use, and the behavior and side effects were monitored related to the use of quetiapine. In addition, Resident 24's medical record failed to show monthly psychotropic summaries related to the use of quetiapine were completed and a plan of care was formulated for the use of the medication. [...]

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 8%. One licensed nurse (LVN 3) was found to have made errors during the medication administration observation. * Resident 3 had a physician's order for ocular lubricant ophthalmic solution and chlorhexidine (antiseptic) mouthwash which were scheduled at 0800 hour; however, LVN 3 failed to administer the medications as scheduled. This failure had the potential to negatively effect the resident's health.

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the medications were properly stored and labeled. * The facility failed to ensure the safe storage and dispose of Resident 16's expired medication found on his bedside table. * Resident 1 had a physician's order for vitamin D. Resident 1's vitamin D liquid bottle was observed with an unknown substance accumulated on the outside of the bottle. These failures had the potential to negatively impact the residents' well being.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by: * The facility failed to ensure the cutting boards were kept in a sanitary condition and with cleanable surface. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and were not worn out. * The facility failed to ensure the kitchen utensils were clean and free of food particle or residue. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the microwave utilized to warm up the residents' food was in sanitary condition and free of food residue. * The facility failed to ensure the plumbing for the ice machine in the kitchen had an air gap. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure the appropriate infection control practices designed to provide the safe and sanitary environment were implemented. * The facility failed to record all the residents with infection on the facility's Infection Surveillance Tool. The facility's Infection Surveillance Tool did not include all the residents identified with infections. Only the residents with positive culture results were identified as having infection and were listed on the surveillance list. * The facility failed to ensure the laundry room's soap bucket was kept clean and failed to keep the soap bucket off the floor surface. * The facility failed to remove the isolation signage after the neutropenic precaution order was discontinued for Resident 5. [...]

Inspectors wroteBased on interview, medical record review, and facility P&P review, the facility failed to implement their Antibiotic Stewardship Program when: * The facility failed to conduct an assessment for the McGeer's criteria for one of 12 final sampled residents (Resident 15), and two nonsampled residents (Residents 17 and 676) * The facility failed to notify the physicians regarding the McGeer's criteria were not met for true infection for two of 12 final sampled residents (Residents 3 and 19) and one nonsampled residents (Resident 12) These failures had the potential for inaccurately identifying for true infections and potentially inhibited the residents' physicians from discontinuing the unnecessary antibiotics.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the COVID-19 vaccinations were administered to one of 12 final sampled residents (Resident 9) after receiving the consent from Resident 9's responsible party. This failure placed the resident at risk to acquire COVID-19 infection.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure the comprehensive plans for four of the 12 final sampled residents (Residents 3, 8, 16, and 24). * The facility failed to develop the comprehensive care plans for Residents 3 and 16's use of padded side rails for safety/injury protection. * The facility failed to ensure Residents 8 and 24's plans of care were revised to address Residents 8 and 24's use of seat belt and chest strap restraints in the wheelchair. These failures posed the risk of not providing the appropriate, consistent, and individualized care to the residents.

Inspectors wroteBased on interview, medical record review, and facility P&P, the facility failed to ensure the medical record for one of 12 final sampled residents (Resident 19) was complete and accurate. This failure had the potential for the resident's care needs not being met as the medical information was incomplete and inaccurate.

Inspectors wroteBased on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to meet the care needs related to the tracheostomy care for one of the three sampled residents (Resident 2). * The facility failed to ensure the tracheostomy care was provided to Resident 2 as per the facility's P&P. This failure posed the risk for not keeping the stoma area clean and being susceptible to infection.

Inspectors wroteBased on observation, interview, and facility record review, and facility P&P review, the facility failed to ensure the hand hygiene practices were performed after removal of gloves as per the facility's P&P. This failure had the potential for transmission of disease-causing microorganisms and infections to the residents.

Inspectors wroteBased on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) received the incontinence care in a timely manner when Resident 1 waited for an hour to receive care. This failure resulted in Resident 1's incontinence brief to overflow with urine unto the floor, which had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation and medical record review, the facility failed to comply with the State laws for one of two sampled residents as evidenced by: *A facility staff (CNA 1) was observed applying the antifungal ointment on Resident 1. This failure had the potential to not provide the necessary care and services to meet the resident's care needs.