Grossmont Gardens Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure written information regarding an advanced directive (a legal document indicating resident preference on end-of-life treatment decisions) was provided to 10 of 12 sampled residents (14, 8, 12, 19, 15, 7, 20, 5, 6 and 2). This failure resulted in Residents 14, 8, 12, 19, 15, 7, 20, 5, 6 and 2 not having the opportunity to express wishes for care should they lose decision-making capacity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement resident-specific written care plans for five of 12 residents (11, 16, 20, 14, and 5) when:1. Resident 20's preference for personal belongings was not developed in her care plan.2. Resident 11's written care plan for skin and the use of the low air loss mattress (LAL, a specialized mattress that uses air flow to prevent pressure injuries) was not implemented.3. Resident 16 did not have a care plan developed for his use of the LAL mattress.4. Resident 14's use of clip alarm (a device used to alert staff when a resident was getting up unassisted) was not developed in the fall care plan.5. Resident 5 did not have a care plan developed for continuous oxygen administration. [...]

Inspectors wroteBased on observation, interview, and facility P&P review, the facility failed to ensure food safety and sanitation guidelines were followed when: The cool down process for time, temperature control for safety (TCS) food, food that needs to be kept at specific temperatures to prevent bacteria growth and foodborne illnesses, was not monitored. 2. Gloves were not used appropriately. 3. Facial hair was not covered. These failures posed the risk for foodborne illnesses in a highly susceptible resident population of 21 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 12 residents (Resident 20) was treated with dignity and respect when Certified Nursing Assistant (CNA) 1 moved the resident's personal belongings without the resident's permission. As a result of this failure, Resident 20 expressed frustration and was upset. A review of Resident 20's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness affecting one side of the body) following a stroke and aphasia (communication disorder resulting from brain damage). On 2/9/26 at 10:20 A.M., an observation was conducted inside Resident 20's room. Resident 20 appeared upset when asked how she was feeling. Resident 20 had difficulty communicating and stated all her belongings were gone without her knowledge. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one out of five sampled residents (Resident 14) was free from unnecessary psychotropic (affecting brain activities associated with mental processes and behavior) medication when Resident 14 was prescribed a psychotropic medication as needed for more than 14 days. This failure had the potential for Resident 14 to receive an unnecessary psychotropic medication which can lead to side effects, such as sedation and falls, physical dependence (experiencing unpleasant symptoms if a medication is suddenly stopped), respiratory depression (slowed or shallow breathing) and a decline in psychosocial (how a person feels about themselves and their environment) well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure interventions to prevent the development of pressure injuries (tissue injuries that develop from prolonged pressure) were utilized according to physician's orders for two of three residents (11 and 16) when low air loss mattresses (LAL, a specialized mattress that uses air flow to prevent pressure injuries) were not set to the residents' weight. These failures had the potential to cause pressure injuries. Cross reference F656.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe and effective pharmaceutical services when:Random controlled medication (medications with a high abuse potential) use audit for three of six sampled residents (Residents 7, 1, 4,) indicated medications were signed out of the controlled drug record (CDR, count sheet used to track controlled medications), but were not documented on the Medication Administration Record (MAR, section of the medical record where all medications given to the resident are recorded to ensure patient safety) to indicate they were administered to the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 15% when six medication errors occurred out of 40 opportunities during the medication administration for three of six randomly observed residents (Residents 1, 4, and 16). These failures had the potential for the residents not to get the full therapeutic benefit of their medications or to experience negative health outcomes, such as harm from exposure to medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication labeling in accordance with accepted professional standards when Licensed Nurse (LN) 21 administered an opened and unlabeled inhaler mouthpiece to one of six residents (Resident 16) observed during medication administration. This failure had the potential for residents to receive the wrong inhaler, which could result in adverse resident outcomes, infections from accidental cross-contamination (germs), and medication errors.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure that the Food Services Manager (FSM), who oversees the kitchen serving the skilled nursing facility, was qualified to manage the day-to-day operations of the food services department. This failure had the potential to negatively affect the health and well-being of 21 residents who received the food prepared in the kitchen.

Inspectors wroteBased on observation, interview, facility document review, and facility P&P review, the facility failed to prepare foods in a form designed to meet individual needs when facility recipes were not followed for fortified foods (foods that have nutrients added to them that were not originally present). These failures had the potential to result in decreased food and nutrient intake for 6 of 6 residents on fortified diets.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide special required adaptive eating equipment (specially designed utensils and tools that help individuals eat more easily) for a resident during meals. This failure had the potential to negatively impact the health and well-being of one resident who received food prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurately documented records when the wrong indication (reason for taking a medication) was electronically transcribed on the Medication Administration Record (MAR, an official legal document that has a complete and accurate record of all medications administered to a resident to ensure patient safety) of one out of five sampled residents (Resident 5). This failure resulted in inaccurate documentation in Resident 5's medical records and had the potential to negatively affect the treatment and assessment of her medical conditions.

Inspectors wroteBased on interview and record review, the facility's QAA/QAPI (Quality Assessment and Assurance/ Quality Assessment Program Improvement) committee failed to identify, develop, and implement action plans related to advance directives (cross reference F 578). This failure had the potential for residents not to have the opportunity to exercise their rights to formulate an advance directive.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement proper infection control practices in one of one Medication Rooms and in one of six sampled residents (Resident 7) when:The soap dispenser in the Medication Room was not working. Licensed Nurse (LN) 21 did not perform hand hygiene after touching a potentially contaminated surface during medication administration through a feeding tube (a surgically placed tube used to administer food and medications in individuals who have trouble swallowing) for Resident 7. These failures had the potential to put residents, staff and visitors at risk for infections due to cross-contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that side rails were properly maintained for one out of one resident (Resident 14) when the resident's side rails were loose and unsteady. This deficient practice had the potential to result in the resident being entrapped in between the bed and the side rail.