Gateway Post Acute

Inspectors wroteBased on interview and record review the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect. This failure had the potential for negative outcomes and potential for Resident 1 to have low self esteem.

Inspectors wroteBased on interview and record review the facility failed to implement their policy and procedure for an allegation of verbal/mental abuse for one of three sampled residents (Resident 1). This failure had the potential for further abuse to occur.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Certified Dietary Manager (CDM) met state education qualifications to supervise Food and Nutrition Service (FNS) operations. Specifically, the CDM lacked the required six hours of in-service training on California dietary service requirements per Title 22 (Section 72035) of the California Code of Regulations and CA Health and Safety Code (HSC) 1265.4(b) Pathway 4. This failure had the potential to adversely affect the facility's ability to ensure the nutritional, health, and safety needs of the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled staff, one Registered Nurse (DON) and two Licensed Vocational Nurses (LVN 2, and LVN 4) had a competency evaluation to demonstrate skill profeciencies for management of:1. wound vac (vaccum, a medical device that uses negative pressure therapy to speed up wound healing, it involves a vacuum pump, a drainage canister, and specialized foam dressing that is applied over the wound bed that removes fluid, reduces swelling and increases blood flow to stimulate tissue growth) dressing change prior to performing this task.2. colostomy (a surgical procedure where an opening is made in the colon and brought to the surface of the abdomen to allow stool to exit the body) bag. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meal preferences were honored for one of 21 sampled resident (Resident 20). This failure had the potential for decreased meal intake, weight loss, resident dissatisfaction and a reduced quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and sanitary food handling practices when:1. Food delivery boxes were stored directly on the floor in the dry food storage room posing a risk for contamination.2. Clean foodservice preparation equipment was stored directly on shelving with rust and chipped paint exposing food-contact surfaces to risk of physical and cross- contamination (Physical contaminants are foreign objects that may inadvertently enter the food).3. The foodservice operation did not follow the manufacturer's guidelines for the cleaning/sanitizing product that was in use for food contact surfaces, impeding effective cleaning and sanitizing processes. The U.S. Food and Drug Administration (FDA) Food Code 2022 indicated it is critical to sanitization that the sanitizers are used consistently with the EPA [U.S. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policies and procedures (P&P) and/or the P&P lacked sufficient guidance to staff to ensure safe and sanitary storage, handling, and consumption when:1. Food items brought in from the outside for residents were not consistently labeled, dated, and monitored to ensure safe food storage and consumption. This failure posed a risk to food quality and/or safety, and may result in residents not receiving their intended food due to misidentification.2. The staff failed to ensure food stored in refrigerators did not exceed 41 degrees Fahrenheit (F - the standard maximum safe temperature for cold food storage to guide staff). This failure resulted in the risk of foodborne illness from spoiled food.3. The staff failed to ensure the resident refrigerator was clean and sanitary when extensive debris was noted. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard practice for infection control when:1. Six of Six sampled residents (Resident 68, Resident 23, Resident 13, Resident 59, Resident 1, and Resident 71) were not provided hand hygiene prior to meals. This failure had the potential to spread infection to residents.2. Two of two sampled Licensed Vocational Nurses (LVN 1 and LVN 2) did not clean and disinfect glucometers (small portable medical device used to measure the approximate concentration of glucose in the blood) after use. This failure had the potential to spread disease causing organisms to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the minimum square footage as required by regulation in four of 27 facility bedrooms. This had the potential to affect the care and safety of residents.

Inspectors wroteBased on interviews and record review, the facility failed to uphold the rights of one of four sampled residents (Resident 14) when Resident 14 wanted his curtains closed. This failure resulted in Resident 14 being unable to exercise his preferences.

Inspectors wroteBased on interview, and record review, the facility failed to implement one of two sampled resident (Resident 9) physician order for colostomy ( a surgical procedure where an opening is made in the colon and brought to the surface of the abdomen to allow stool to exit the body) bag change every week. This failure had the potential to result in resident's care not being met with the likely of infection to the colostomy site.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of two sampled resident (Resident 5), had a comprehensive (complete) care plan (CP). This failure had the potential to result in Resident 5 not having measurable objectives and timetables to meet the residents physical needs.

Inspectors wroteBased on observation, interview, and record review the failed to follow its policy and procedure (P & P) tilted Elopements, for one of four sampled resident (Resident 38) when Resident 38 exited the building unsupervised. This failure had the potential for Resident 38 to cause harm to self or an injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was accurate and consistent communication between departments regarding adaptive equipment for one of one sampled resident (Resident 51). This failure had the potential to result in unnecessary and/or unmet implementation of adaptive equipment per Resident 51's assessment and/or physician's orders, to meet Resident 51's specialized nutritional needs and enhance quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a [NAME] followed standardized texture modified recipes for seven of 56 residents (Resident 7, Resident 8, Resident 21, Resident 26, Resident 31, Resident 49, and Resident 56) as a method to maintain nutritive value. This failure had the potential to result in texture modified food with less nutritive value than planned, placing residents on a pureed diet at risk for nutritional impairment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 18 sampled residents (Resident 57) had accurate wound records due to unclear physician's order (PO). This failure resulted in Resident 57 having documentation that did not accurately represent the care provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the needs for one of two sampled residents (Resident 1) when a STAT (immediately) x-ray (takes pictures of areas inside the body) ordered by the physician was not completed timely. This failure has the potential for a delay in care for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Infection Preventionist (IP-responsible for the implementation and review of the facility's infection prevention program) managed pain for one of one sampled resident (Resident 51) during wound dressing change on the open wound to the amputated left big toe and the vascular wound on the inner aspect of the left ankle. This failure resulted in Resident 51 experiencing pain as evidenced by facial expressions and pain level of nine out of 10 (0-no pain, 1-verbal, 3-mild pain,4-5 moderate pain, 6-9 severe pain, 10-excruciating pain).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The Infection Preventionist (IP) did not use appropriate personal protective equipment (PPE-refers to gowns, gloves, masks, face shields, goggles to protect the individual from injury or infection) and did not perform appropriate hand hygiene for one of one sampled Residents (Resident 51), 2. Conduct an effective infection control surveillance activity through data collection, data analysis, track, and trending for 57 of 57 residents residing in the facility. These failures had the potential to transmit infectious diseases.

Inspectors wroteBased on interview and record review, the facility failed to implement Antibiotic Stewardship (pharmacy-driven initiative dedicated to improve antibiotic [medications to treat bacteria] / antifungal [medications to treat fungus] use in nursing homes). This failure had the potential for residents to receive antibiotic and/or antifungal medications unnecessarily, which could be detrimental to residents' health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 51) was assessed and determined to be competent to self-administer medication. This failure had the potential for medication administration error and serious health risk.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Notify the physician for the discontinuation of the restorative therapy (therapeutic and rehabilitative techniques provided by specially trained restorative nursing assistant [RNA]) for one of one sampled resident (Resident 21). This failure had the potential for Resident 21 to not meet his full potential for mobility. 2. Notify the physician for the swelling and purplish discoloration of the left big toe and wounds on the left big toe for one of one sampled resident (Resident 2). This failure had the potential for Resident 2's wounds to be untreated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment for two of 15 sampled residents (Resident 46 and Resident 162). This failure resulted in these residents living in an unkempt environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures (P&P) titled, Certifying Accuracy of the Resident Assessment, for one of one sampled resident (Resident 35). This failure had the potential to not meet Resident 35's dental needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 3) had a psychiatric and a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure placement in nursing facility was appropriate) Level 2 evaluation after a PASRR Level 1 indicated the need for evaluation of his mental disorder. This failure had the potential for Resident 3 to be inappropriately placed in a nursing home and had the potential to not receive the mental health treatment needed. During a concurrent interview and record review on 10/15/24 at 10:15 a.m. with Minimum Data Set (resident assessment tool) Coordinator (MDSC) 1, Resident 3's PASRR Level 1 Screening, dated 1/15/24 was reviewed. Resident 3's PASRR Level 1 indicated Level 1 Screening: Positive. Section III Serious Mental Disorder: Yes Diagnosis: [...]

Inspectors wroteBased on interview and record review, the facility failed to complete and provide two of two newly admitted sampled residents (Resident 51 and Resident 109) and/or their representatives a summary of the baseline care plan (BCP-the minimum healthcare information to care for each resident upon admission) within 48 hours of admission. This failure had the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, for one of 18 sampled residents (Resident 22). This failure had the potential to not meet Resident 22's physical, psychosocial (related to thought or behavior), and functional needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure to one of 11 sampled residents (Resident 5) were administered medications according to physician orders. This failure had the potential for Resident 5 to have adverse medication outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 7) was provided activities of her choice. This failure resulted in Resident 7 not participating in person centered activities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 18 sampled patients (Patient 15) was provided quality care when: 1. A Care Plan (CP) for pain management was not developed. 2. The admission Nursing - Pain Observation and Assessment (NPOA) was incomplete, and reassessment was not done. These failures resulted in Patient 15 experiencing unrelieved pain and a feeling of isolation.

Inspectors wroteThe facility failed to follow its policy and procedure (P&P) titled Repositioning for one of one Residents (Resident 22). This failure had the potential for Resident 22 to develop pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an appropriate diet texture (consistency of food or the size of food pieces) was provided to one of 15 sampled residents (Resident 16). This failure had the potential to cause Resident 16 to choke on her food or have an adverse outcome.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 17) had complete pre-dialysis and post dialysis communication assessments. This failure had the potential for Resident 17 to have a change of condition that was not communicated and could result in negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Bed Safety and Bed Rails, for one of 18 sampled residents (Resident 55) when: 1. The bed rail and entrapment risk observation/assessment (BEAR) was inaccurate and incomplete. 2. The Interdisciplinary Team (IDT - team of health care professionals) was not involved in the review of use of bed rails. 3. There was no physician's order for continuous use of bilateral (right and left) bed rails. 4. There was no Care Plan (CP) for use of bilateral bed rails. This failure resulted in Resident 55's IDT had the potential to put Resident 51's safety and health at risk.

Inspectors wroteBased on interview, and record review, the facility failed to employ a full time Director of Nursing (DON) for a facility licensed for 62-beds. This failure resulted in lack of oversight on the total operation of nursing services and provision of quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three medication carts did not contain expired medication. This failure had the potential for a medication with reduced effectiveness to be administered to a resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was five percent or less when two medication errors were observed out of 25 medication administration opportunities, which resulted in a medication error rate of 8%. These failures had the potential for residents to not receive the therapeutic effects of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 10 sampled residents (Resident 109) was free from a significant medication error. This failure had the potential for Resident 109 to adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three kitchen staff (Dietary Service Supervisor [DSS] and Kitchen [NAME] [KC])followed their policy and procedures (P&P) titled, DRESS CODE FOR WOMEN AND MEN, This failure had the potential for food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure intake and output was monitored for one of four sampled residents (Resident 1) when Resident 1 was on a fluid restriction. This failure resulted in the facility being unaware of Resident 1 ' s fluid intake and output.

Inspectors wroteBased on interview and record review, the facility failed to develop a Care Plan (CP) for one of three sampled residents (Resident 1) after a fall. This failure had the potential for Resident 1 to experience further falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was properly secured during transportation when: 1. Seatbelt was loosely fastened unto Resident 1's wheelchair. 2. Footrest (a removable footplate where the feet are placed to avoid injury and maintain balance) was missing from Resident 1's wheelchair. These failures resulted in Resident 1 falling out of wheelchair, sustaining skin tear to right wrist and abrasion (scrape) to right shin.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Advance Directives (a document indicating a person's wishes for end-of-life care) when staff did not facilitate formulation of Advance Directives for 7 of 33 sampled residents (Resident 1, Resident 22, Resident 26, Resident 35, Resident 41, Resident 43, and Resident 45). This failure had the potential for staff to be unaware of the medical treatment to be provided to resident, when they no longer able to make decisions in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Follow its policy and procedure (P&P) for administering medications through an enteral tube (GT- Gastrostomy tube, surgically placed through the abdominal wall to the stomach) by gravity flow for one of 33 sampled residents (Resident 2). This failure had the potential for Resident 2 to experience aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs). 2. Follow physician's orders for administration of oxygen (a colorless, odorless reactive gas, a life-supporting component of the air) for one of 33 sampled residents (Resident 14). This had the potential to result in unmet care needs and adversely affect resident's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to maintain good oral hygiene for one of 33 sampled residents (Resident 2). This failure resulted in Resident 2's having poor oral hygiene with presence of cracked dry lips and can lead to dental and gum disease.

Inspectors wroteBased on interview and record review, the facility failed to clearly document in the clinical record for one of 33 sampled residents (Resident 35's) wishes in the event of cardio-pulmonary arrest (heart stops, no breathing). This had the potential for staff not knowing if they should perform cardio-pulmonary resuscitation (CPR, when trained staff give chest compressions and rescue breathing) to Resident 35.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate activities based on interest and preferences for one of 33 sampled residents (Resident 34). This failure had the potential to negatively impact Resident 34's psycosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to facilitate an audiology consult for one of 33 sampled residents (Resident 160). This failure resulted in a delay in the provision of assisstive hearing devices which hindered Resident 160's ability to communicate effectively.

Inspectors wroteBased on observation and interview, the facility failed to refer and provide podiatry (treatment of the feet) service for two of 33 sampled residents (Resident 2 and Resident 160). This failure resulted on not meeting the care needs of Resident 2 and 160.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing competency assessments for 2 of 5 sampled staff (LVN 7 and CNA 8) were completed. This failure had the potential for unqualified nursing staff to provide the health care needs of Residents.

Inspectors wroteBased on interview and record review, the facility failed to conduct a performance review at least once a year for one of five sampled Certified Nursing Assistant (CNA) 8. This failure had the potential for CNA 8 to not provide the appropriate care to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) to provide necessary behavioral health services for one of 33 residents (Resident 45). This failure had the potential to result in Resident 45's inability to attain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%) when three medication errors occurred out of 30 opportunities during gastrostomy tube (GT- surgically placed tube through the abdominal wall and into the stomach) medication pass for one of five sampled residents (Resident 2). The medication error rate was 10%. This failure had the potential to cause serious harm and injury to resident for not receiving the full dosage of medications ordered by the physician.

Inspectors wroteBased on observation and interview, the facility failed to provide the required minimum square footage (sq. ft. - 80 sq. ft. per resident for multiple resident rooms is the minimum required by regulation) in two of 26 rooms. This failure had the potential to affect the care of the residents in those rooms.