Glendale Adventist Medical Center Dp/SNF

Inspectors wroteBased on observations, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards and the facility's policy and procedures titled Food Storage for food service safety by ensuring the hospital food was properly labeled and dated with the product name, date product was opened or prepared and use by date by: An open box of Dark Chocolate Cocoa Mix with individually wrapped packets had no open date. 2. An open plastic container with lentils had no label to identify its contents or indicate the use-by date. 3. A multi-rack with metal trays that had food items without label or use-by-dated. 4. A bag of carrots with a large tear on the package had no label and use-by-date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 6 and 45) received appropriate treatment and services to prevent urinary tract infections (UTI a infection of the urinary tract that includes urethra, ureters, bladder and kidneys resulting when microorganism gets into the urine and travels to the urinary tract) by failing to ensure: 1. Resident 6's suction tubing that connects to Resident 6's Pure Wick System (PWS- an external female catheter use for urine collection for residents that are incontinent [no control] of bladder when urinating) was covered and placed in a plastic bag when disconnected from Resident 6 was not left on top of Resident 6's pillow and the urine collection cannister connected to the tubing was labeled or dated of the last time it was changed. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement facility's policy and procedure to prevent spread of infection for two of two sampled residents at risk or with infection by failing to: 1. Resident 34's nasal cannula (NC-a flexible tube with two prongs that rest in the nostrils to deliver supplemental oxygen) was observed in her room without a plastic bag and a label or date of the last time it was changed. The facility's policy indicated to changed NC every 7 days. 2. Biomedical Technician (BT) did not perform hand hygiene and don (put on) PPE (Protective equipment and clothing such as gown and gloves used to prevent the spread of infectious organisms) before and after entering Resident 44's, who was placed on contact isolation (precautions taken in healthcare settings to prevent the spread of infections). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled patient (Resident 1) received Keppra (seizure [uncontrolled shaking, loss of body movement, function, and consciousness] medication), when Resident 1 was placed on NPO (nothing by mouth) by the physician and there was no communication between staff and physician regarding Resident 1's alternatives to receiving the medication. This deficient practice may have contributed to Resident 1 having a seizure the following morning, when Resident 1 did not receive Keppra for over 12 hours.

Inspectors wrote2. A review of Resident 153's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) and sepsis (a life-threatening medical emergency that occurs when the body's immune system has an extreme response to an infection). A review of Resident 153's Orders dated 8/14/24, Orders indicated Resident 153 was ordered a Dysphagia Diet (a diet for people who have difficulty swallowing). During a concurrent observation and interview on 8/17/24 at 8:48 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed standing while assisting Resident 153 to eat. LVN 1 stated, I'm not sure if we have to be sitting at the same level of the resident when we are helping to feed residents. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards and the facility ' s policy and procedure for food service safety by ensuring the hospital food were properly labeled and dated with the product name, date product was opened or prepared and use by date. The facility failed to: 1. Label and put an expiration date on a tub of cookies in the freezer. 2. [NAME] the jar of slaw with open date or use by date. 3. Label food in cart trays 4. Dispose of expired veggies in cart 5. Dispose of dirty cans of soda in the refrigerator 6. Dispose of bag of cabbage that had two expiration date labels. 7. Label and date meat package 8. Store ice machine scoop not on the ice. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services for one of eight sampled residents (Resident 149) who was at risk for developing blood clot by failing to apply sequential compression device (SCD- a device use on the legs to promote blood circulation and prevent blood clot to develop) as ordered by the physician. This deficient practice had the potential to cause a deep vein thrombosis (DVT; blood clot that forms in a deep vein, often in the legs, from lack of blood circulation and potentially cause pulmonary embolism (PE is when a blood clot breaks off from inside a vein and travels to the lungs and causes respiratory distress), heart attach (heart stop functioning) and stroke (interruption of blood flow to the brain)

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for one of one sampled residents (Resident 8) by failing to label Resident 8's peripheral intravenous line (IV, a thin flexible tube was inserted through the skin into a small vein in the periphery to deliver fluid and medications) to indicate the date the IV was inserted. As a result of this deficient practice had the potential for the IV not to be changed timely and could result in phlebitis (inflammation/swelling of the vein) or develop infection in the peripheral IV site that could enter the blood stream and result in severe infection.

Inspectors wrote4. A review of Resident 235's admission Record indicated the facility admitted the resident on 8/1/2023. During a review of Resident 235's H&P, dated 8/2/2023, indicated the resident was confused and bedridden (confined to bed by sickness or old age), with diagnosis that included dementia and depression. During a concurrent observation and interview on 8/5/2023 at 1:47 pm, Resident 235 was lying in bed. Resident 235's Family 1 (FAM 1) stated, Resident 235 did not want to eat and would get angry when assisted to be fed. FAM 1 stated Resident 235 would usually eat homemade soup but refused to eat now. During a concurrent record review of Resident 235's Physician Orders and interview with MDSN 1 on 8/6/2023 at 10:17 am indicated, the physician ordered Resident 235 to receive Sertraline. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases (one that is spread from one person to another through contact with blood and bodily fluids, or breathing in an airborne virus) for five of 5 sampled residents ( Residents 136, 17, 21, 5 and 85) by failing to: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of need by ensuring the call light was within reach as indicated on the facility's policy and procedure, titled Answering of Call Lights and resident's Care Plan for one of one sampled resident (Resident 135) who was at risk for fall. This deficient practice had the potential for the resident not to receive or received delayed care to meet the necessary care and services that could result in fall and accident.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a resident specific plan of care to prevent development and/or worsening Stage 2 pressure ulcer (a skin injury or ulcer resulting in partial-thickness skin loss with exposed open skin due to prolonged pressure or being in one position for prolong period) in accordance with the facility's policy and procedure for one of two sampled residents (Resident 89). Resident 89's plan of care did not indicate interventions on how often the resident will be repositioned and turned while in bed, how to keep resident clean and dry. This deficient practice resulted in Resident 89 not to receive the necessary care and services to prevent the worsening of pressure ulcer that could result in pain, discomfort, and wound infection. Cross reference to F686.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with facility's policy and procedure to prevent the development or worsening of pressure ulcer/injury (a skin injury due to friction or shear and for prolonged pressure by being in one position of a long period of time) for two of four residents (Resident 86 and 89) by failing to: 1. Ensure Resident 86 who was using a Low Air Loss Mattress (LAL - mattress composed of multiple inflatable air tubes that alternately inflate and deflate designed to prevent and treat pressure ulcers) was set in a correct setting based on the manufacturer's recommendation. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and monitor the presence of white sediments (visible particles in the urine that may contain red or white blood cells, casts, bacteria, fungi, parasites in the urine that could indicate infection or dehydration [fluid deficit]) in the urine for one of 2 sampled residents (Resident 21) with indwelling catheter (a tube inserted in the bladder to drain urine into a drainage bag), as indicated in the facility's policy and procedure, titled Care of Indwelling Catheter and the resident's Care Plan. [...]