Grossmont Post Acute Care

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a peripherally inserted central catheter (PICC, a long, thin and flexible tube [catheter] that is inserted into a vein in the upper arm for medication administration) was measured weekly for one of two residents reviewed (Resident 1). This failure resulted in Resident 1 returning to the hospital with chest pain, removal of the PICC, and replacement with another catheter to complete medication administration.

Inspectors wroteBased on interview and record review, the facility failed to obtain a chest x-ray (an image of the chest that shows lung problems) as ordered for one of two sampled residents (1). As a result, there was an increased risk of Resident 1 to receive a delay in care or incorrect treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary care monitoring, and interdisciplinary (IDT) coordination to prevent respiratory depression (hypoxia and loss of consciousness) and excessive sedation, when administrating multiple central nervous system (CNS) depressant medications (mirtazapine a medication for depression/mood, oxycodone a strong pain-relieving medicine, and alprazolam a medication for anxiety) for one of three sampled residents (Resident 1). This had the potential for Resident 1 to experience a significant decline in respiratory status from hypoxia.

Inspectors wrote2. Resident 1 was admitted to the facility on [DATE], with diagnosis including bone cancer, per the admission Record. A review of Resident 1's clinical record using the Electronic Medical record system on 6/18/25 could not locate a POLST. On 6/19/25 at 8:49 A.M., the Medical Records Director found the physical POLST. The POLST was signed and dated by the MD, but the Signature of Patient or Legally Recognized Decision maker had the printed name of Resident 1's grandson. In the area for his signature was the word verbal with a date of 4/4/25. There was no signature of the person getting a verbal consent and no indication that they had attempted to get a signature from anyone since that date. [...]

Inspectors wroteBased on record review the facility did not develop a care plan for a pacemaker (implanted device that regulates your heartbeat) for one of 18 sampled residents (34). As a result, the facility staff would not know if the pacemaker was malfunctioning.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to follow physician-ordered oxygen therapy and ensure safe care practices for one of 18 sampled residents (Resident 286). This deficient practice placed all residents with respiratory disorders at risk for receiving unsafe care due to staff performing duties they were not trained or authorized to do.

Inspectors wroteBased on observation, interview and record review, the facility failed to label (name, date, time, and dose) an intravenous fluid (IVF: hydration therapy given through the vein) therapy and discarding the IVF according to their policies and procedures for one of 18 sampled residents (Resident 275). In addition, the IVF bag and tubing was moved in next to a different resident's bedside and was left uncapped (open to infection). This deficient practice placed all residents receiving IVF and/or IV medications at risk for infection, medication errors, and unsafe care due to improper handling and storage of IVF.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that certified nursing assistants (CNA) followed safe and appropriate procedures when providing oxygen administration to one of 18 sampled residents (Resident 286). This deficient practice placed all residents with respiratory disorders at risk for receiving unsafe care and potential harm due to nursing staff performing tasks they were not trained or allowed to do.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document: 1. The disposition of a discharged resident from the facility for one of three residents (Resident 73), reviewed for closed records; and 2. Every two hours, the lint removal in the dryer's maintenance log within the facility's laundry room, reviewed for infection control. These failures resulted Resident 73's location not being known to the reader after discharge and laundry staff being unable to verify when the dryer lint was last removed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 1), who was cognitively impaired and dependent on staff for care, was free from abuse when certified nursing assistant (CNA) 2 called the resident an ass then smacked the side of his head with an open hand while telling the resident, That's for hitting me last week. As a result, Resident 1 became agitated and attempted to hit staff back. In addition, Resident 1 had seemed guarded following the incident, per staff interview. This deficient practice had the potential to cause Resident 1 to experience fear, humiliation, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to implement one resident's (Resident 1) written care plans related to behavior as evidenced by angry outbursts after the resident hit a staff member during care. As a result of this deficient practice, Resident 1's behavior was not documented in the resident's clinical record and it was not reported to the physician as indicated in the resident's written care plans. This had the potential for the resident's behavior to go unmanaged.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their own policy when Resident 1 was transferred from bed to wheelchair without the use of a gait belt (assistance safety device). This failure resulted in Resident 1 ' s injury of chipped fracture to his right tibia (shin bone). Findings. A review of the Facility ' s undated admission Record indicated, Resident 1 was admitted on [DATE] with diagnoses that included Repeated Falls, Cognitive Communication Deficit and Retention of Urine Unspecified. An interview on 4/23/24 at 10:55 A.M., with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated she was supposed to be watching lights and provide assistance to residents when needed. CNA 1 stated if a resident wants to be left alone, CNA 1 will leave them alone but would be watching from a distance. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure effective dietetic systems related to food and nutrition services were executed according to facility policy and standards of practice when: 1. A resident's (Resident 6), nutrition care plan was not carried out, and experienced unintentional weight loss. 2. Kitchen staff were not trained in day-to-day food safety and sanitation practices. 3. Residents' meals were not served at palatable temperatures according to policy. 4. Expired foods, dirty dishes, and dirty equipment were found in the kitchen. 5. Kitchen equipment was not maintained for proper operation. These deficient practices led to a resident to experience unintentional weight loss, and exposed 81 residents to unsafe and unsanitary food practices, which may have further compromised their nutrition status. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure kitchen staff received the competencies and training needed to perform their job duties when: 1. A [NAME] could describe the cool down process for cooked foods, and 2. A Diet Aide could not describe the correct temperatures of the three-compartment sink for manual dish washing These failures placed residents at risk of cross contamination and acquiring food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food safety and sanitation practices were met in the kitchen according to standard of practice when: 1. A tray with fourteen small glasses of milk and four glasses of juice each dated 7/14/23, were on the shelf for use in the walk-in refrigerator. 2. The kitchen's clean dish storage area had dirty serving utensils and food items stored on them. 3. The ceiling vent was full of grayish-black dust. 4. The facility did not use a cool down process for ambient temperature prepared foods. 5. An ice cream freezer door gasket had dark brown and black stains and was not clean. These failures exposed residents' to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a Minimum Data Set (MDS, an assessment tool) was accurately coded for one of 18 residents (Resident 59) reviewed for accurate MDS. This failure had the potential for Resident 59 to receive inappropriate care due to inaccurate diagnosis.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the nutrition care plan was implemented for one of 18 residents reviewed for care plans. (Resident 6) This failure resulted in Resident 6 not receiving foods listed in the care plan, which may have led to the resident's continued gradual weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure adequate nutrition was provided for one of two sampled residents with severe weight loss in less than one month. (Resident 6) This failure had the potential to result in Resident 6's further unintentional and unplanned weight loss.

Inspectors wroteBased on Interview and Record Review, the facility failed to accurately record medications given for one of one resident reviewed for IV medication administration. This failure had the potential for harm, leading to missed or additional medication being given.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their Infection Prevention Program, when: 1. A Certified Nursing Assistant (CNA 3) did not disinfect the vital signs machine between each resident use. 2. The Business Office Manager (BOM) did not perform hand hygiene when delivering meal trays to the residents. This failure had the potential to spread infections between residents.

Inspectors wroteBased on observations, interviews, and document reviews, the facility failed to ensure essential kitchen equipment and vents were maintained and operational according to standards of practice and facility policy. This deficient practice had the potential to negatively affect the temperature of hot and cold foods and expose clean dishes to contaminants from a dirty ceiling vent, which could have led to foodborne illness in 81 residents. During the initial kitchen tour on 7/24/23 at 10:16 A.M. with the Registered Dietitian (RD) and the Dietary of Dietary (DD), a cord connected to the tray line steam table was observed hanging out of the socket. The RD and the DD stated the cord should not be exposed because it may cause damage and it was a safety risk. There was a large air vent with black and gray dirt and lint contaminants observed blowing air directly above a clean dish drying rack. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat with dignity, one of two residents (162) reviewed for resident rights. This failure had the potential to affect Resident 162's physical, mental, emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's procedures for investigating potential abuse for one of one resident (162) reviewed. This failure had the potential for resident abuse to not be reported and investigated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan interventions were developed and implemented for two of 18 residents (364, 362) reviewed for care plans when: 1. A care plan for hearing aids was not developed for Resident 364. 2. A care plan related to swallow precautions was not implemented for Resident 362.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update a resident's care plan to reflect their current condition for one of three residents (56) reviewed for the Bowel and Bladder Program. This failure had the potential to result in Resident 56 receiving inappropriate care for toileting.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of quality were met when neurological examinations (an assessment for level of consciousness, pupil reaction, vital signs, sensory and motor responses for early indication of a head injury) were not conducted for one of five residents (48) reviewed for falls. As a result, there was the potential for Resident 48 to have an undetected, untreated head injury.

Inspectors wroteBased on interview and record review, the facility failed to provide scheduled and requested showers for one of one resident (162) reviewed for ADL. This failure had the potential to affect Resident 162's self-image and confidence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician's order related to the use of an arm sling was followed for one of four residents (362) reviewed for rehabilitation. This failure had the potential to affect Resident 362's comfort and physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess two of five residents (7, 362), reviewed for falls. These failures had the potential to place Residents 7 and 362 at a higher risk for falls and/or injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement incontinence (loss of bowel and/or bladder control) interventions for one of three residents (163) reviewed for the facility's Bowel and Bladder Incontinence Program. This failure had the potential to result in Resident 163 not improving his bowel and bladder continence (control of bowel and/or bladder).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure O2 was administered per physician's order for one of one residents (52), reviewed for oxygen therapy. This failure had the potential to affect the health and well-being of Resident 52.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain was appropriately managed and assessed for two of six residents (39) (63), reviewed for pain management. These failures had the potential to affect the physical and psychosocial well-being of Residents 39 and 63.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired milk that was stored for resident consumption. This failure had the potential to affect the quality of foods containing milk, prepared for residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed when: 1. An RNA did not perform hand hygiene before and after resident contact during meal service for four of 11 residents. 2. A CNA did not perform hand hygiene after removing dirty gloves. 3. A CNA served a resident's meal tray in an unsanitary manner. These failures had the potential to spread infection among residents, staff, and visitors.