Gridley Post Acute

Inspectors wroteBased on interview and record review, the facility failed to provide nursing services in accordance with professional standards of quality for two of six sampled residents (Resident 1, Resident 3). Licensed nursing staff did not adequately assess and monitor Resident 1 after the onset of new pain and emerging signs of clinical decline. The lack of timely nursing assessment and intervention resulted in a delay in transferring Resident 1 to the hospital, where Resident 1 was subsequently treated for sepsis (life-threatening systemic infection) and diverticulitis (inflammation of the gut lining that causes severe pain). Licensed nursing staff did not change Resident 3's Peripherally Inserted Central Catheter (PICC - a long, thin tube that is inserted into a vein in the arm. The tube travels up the vein until it reaches a large vein near the heart. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS - the resident assessment tool) for one of four sampled residents (Resident 3). The facility did not correctly identify the presence of a peripherally inserted central catheter (PICC - a central venous access device used for the administration of long term intravenous medications.)This failure resulted in an inaccurate resident assessment and had the potential to lead to inappropriate care planning and adverse health outcomes for Resident 3.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure smoking occurred only in designated areas, and that proper safety equipment (ashtrays and fire extinguishers) were available for use for one of two sampled residents (Resident 2). This deficient practice had the potential to place all residents at risk for smoking related accidents and hazards.

Inspectors wroteBased on interview and record review, the facility failed to honor the food preferences for one of five sampled residents (Residents 1). This failure had the potential to result in Resident 1 not eating, placing Resident 1 at risk for nutritional deficiencies and unintended weight loss. A review of the facility's undated policy titled, Resident Food Preferences, indicated, If the resident refuses or is unhappy with his or her diet, the staff will create a care plan that the resident is satisfied with. A review of Resident 1's admission Record, indicated that she was admitted on [DATE] with diagnoses of high blood pressure, history of falling, and adult failure to thrive (a multifactorial syndrome where a person experiences a combination of significant weight loss, poor nutrition, decrease physical activity and social withdrawal. Resident 1 was her own health care decision maker. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary mental health services for two of three sampled residents (Resident 1, 2) when:1. Resident 1 did not receive consistent counseling and psychiatric services to meet his mental health need. This resulted in Resident 1 reporting being in a constant state of fear and feeling unsafe in the facility, which had the potential to place Resident 1 at increased risk for self harm and social isolation.2. Resident 2 did not receive psychiatric services to meet his mental health need. This resulted in Resident 2 experiencing increased social isolation and expressing thoughts that they would be better off dead, placing Resident 2 at increased risk for self harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), was treated in a respectful and dignified manner. Resident 1 reported that Certified Nursing Assistant (CNA) A accused the resident of using the call light too often, crossed their arms, and yelled at the resident to shut up. This failure resulted in Resident 1 feeling fearful and worried about possible retaliation from staff.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer a resident to the appropriate state-designated authority for a level II preadmission screening and resident review (PASARR) when 2 (Resident #1 and Resident #2) of 3 sampled residents reviewed for PASARR were diagnosed with a new serious mental illness.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide a bed hold notice upon transfer to the hospital for 1 (Resident #47) of 2 sampled residents reviewed for hospitalization.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's onset of bilateral leg edema for 1 (Resident #15) of 1 sampled resident reviewed for care planning.

Inspectors wroteBased on interview and record review, the facility failed to timely initiate antibiotic therapy for 1 (Resident #47) of 2 sampled residents reviewed for hospitalization.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's environment was free from accident hazards, specifically a space heater for 1 (Resident #1) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to timely notify the physician of laboratory results for 1 (Resident #47) of 2 sampled residents reviewed hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to inform one of three sampled residents (Resident 1) of the risks and benefits of proposed care, treatment, and treatment alternatives in a language she could understand (Spanish) prior to starting a psychotropic (drugs that affect a person's mental state) medication. This failure denied Resident 1's responsible party (RP) her right to participate in Resident 1's treatment decisions and had the potential to affect Resident 1's functional status, rehabilitation and restorative potential, ability to participate in activities, cognitive status, and psychosocial status.

Inspectors wroteBased on interview, and record review, the Medical Director (MD) failed to provide progress notes for one of three sampled residents (Resident 1) that reflected a review of total resident care, current condition (including medications and treatments), and MD decisions about the continued appropriateness of a medical regimen. The facility also failed to work with the MD or seek alternate MD participation to ensure Resident 1 received appropriate care and treatment. This failure had the potential to result in miscommunication of medical diagnosis, treatment, unclear and/or missing direct care staff expectations for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to adequately document the necessity of a psychotropic medication for one of three sampled residents' (Resident 1) with resident-centered indications for use and monitoring for adverse side effect while on Rexulti (an atypical antipsychotic medication). This failure had the potential to result in Resident 1 not maintaining her highest practicable mental, physical, and psychosocial well-being and put Resident 1 at a high risk for physical harm due to adverse consequences.

Inspectors wroteBased on in interview and record review the facility failed to provide the residents food that is palatable (tasty, and flavorful), visually pleasing presentation, and an appetizing temperature for 23 of 47 residents (Residents: 53, 39, 28, 42, 35, 63, 24, 50, 16, 27, 52, 40, 58, 33, 56, 4, 59, 6, 5, 32, 18, 9, and 22) when residents complained of food not tasting good, visually unappealing/unrecognizable presentation, and being cold on a regular basis. This failure had the potential to result in residents not obtaining adequate nutritive intake, precarious weight loss, increased health issue complications, and diminished emotional well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and store COVID-19 (a highly contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2) rapid test kits when the kits stored in one medication cart had expired. This failure had the potential to cause inaccurate test results which could have put the residents at risk for inappropriate care and treatment based on the test results.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food service safety when a case of Glucerna (a sugar-free nutritional supplement protein shake), had expired on 8/1/23, and was still on the shelf and available for use. This failure had the potential to result in health and safety concerns for individual residents that consumed the shake for nutritional supplement.

Inspectors wroteBased on interview and record review, the facility failed to provide one of two sampled residents (Resident 12), a copy of the Resident [NAME] of Rights. This failure had the potential for new residents to be unaware of their rights that maintain quality of life while undergoing care in the skilled nursing setting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan for one of 16 sampled residents (Resident 46), was revised and updated to reflect current individual needs for feeding assistance required. This failure resulted in the resident's individual care needs to go unrecognized, and the potential for a further decline in resident's physical, mental, and psychological status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain consistent placement of hearing aids for one (Resident 27), of six sampled residents. This resulted in difficult communication between Resident 27 and others and had the potential to lead to misidentification of the resident and resulting errors, for example, administration of incorrect medications or treatments.