Kaweah Health Skilled Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was provided dignified care when Resident 1's urine collection bag was not covered and was visible to other residents, staff, and visitors. This failure had the potential to result in emotional distress for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of 17 sampled residents (Resident 19 and Resident 23) were provided an opportunity to formulate an Advance Directive (legal document that specifies a person's medical care and end of life wishes, should the person become unable to communicate those wishes). This failure had the potential for residents' rights to formulate an advance directive, and medical care wishes and/or end of life issues to not be honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure hygiene Activities of Daily Living (ADL- fundamental care tasks such as bathing, dressing, eating, toileting, moving in and out of bed or chair) were provided timely to one of three sampled dependent residents (Resident 7). This failure had the potential for skin breakdown and to negatively impact Resident 7's dignity.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Pressure Ulcer Prevention and Treatment for one of three sampled residents (Resident 7). This failure had the potential to cause pressure injuries (damaged skin and underlying tissue from prolonged pressure) and had the potential to increase Resident 7's susceptibility to pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P), titled SNF Storage of Leftover Patient Food. when a refrigerator was not provided for resident's food brought in by family. This failure had the potential to place residents at risk of foodborne illness due to unmonitored food brought in by the family and could limit food choices and options for residents.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility Medical Director had oversight over medical services and resident care when the medical director did not attend three quarterly Quality Assurance and Performance Improvement (QAPI- data-driven, comprehensive, and proactive approach to improving safety and quality in healthcare, particularly nursing homes) committee meetings. This failure had the potential to compromise patient safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow infection control standards when a germicidal (substance that destroys germs) wipe container was left open exposing the germicidal wipes. This failure had the potential for the germicidal solution to be ineffective against germs which could lead to the spread of illness and diseases to residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of three sampled residents (Resident 1, Resident 2, and Resident 3) or their legal representative were provided prior notification of receiving a new roommate. This failure resulted in a violation of residents' rights.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) care for one of three sampled residents (Resident 1) when Resident 1's fingernails were not cut. This resulted in Resident 1 having long, thick, yellow fingernails and potential for increased risk of nail infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control standards of practice when: 1. The vinyl cover on two of four linen carts in the hallway were damaged exposing the clean linen. 2. The Infection Preventionist Nurse (IPN) did not ensure infection control surveillance was being done on a regular basis. 3. A Wound Treatment Nurse (WTN) did not change gloves or wear gown in good repair during a wound care treatment for one of one sampled resident (Resident 5). 4. An used urinal was on a bedside table for one of one sampled resident (Resident 291). 5. The glucometer machine (measures the amount of sugar in the blood) was disinfected with unapproved wipes for two of two sampled residents (Resident 20, Resident 343). These failures had the potential to cause infections and spread of bacteria to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 342) were answered with a prolonged delay. This failure had the potential for Resident 342 to experience psychosocial harm when she stated the delay made her feel unimportant.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that meet professional standards when: 1. One of five sampled residents (Resident 343) did not have a physician's order severe pain. This failure resulted in Resident 343's severe pain to not be managed. 2. Four of Four Licensed staff (Registered Nurse [RN] 2, Licensed Vocational Nurse [LVN] 4, and RN 1) were unaware of the process of checking for Gastrostomy Tube (GTube - a tube surgically inserted to the abdomen into the stomach)'s placement for three of three sampled residents (Resident 21, Resident 8, and Resident 15). This failure had the potential for Resident 21, Resident 8, and Resident 15 to aspirate (accidental inhalation of foreign substances into the lungs) and had the potential to cause harm or death. 3. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure one of one medication cart (Medication Cart 1) was kept locked or under direct observation by authorized staff. This failure had the potential for residents, unauthorized staff, and visitors to have access to medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure three of three nutritional products available for resident use were not expired. This failure had the potential for residents to develop food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure: 1. Potentially hazardous food (food capable of supporting microbial growth) was documented on the cool down log. 2. Expired food was removed from the freezer in kitchen 2. 3. Frozen food storage was dated in kitchen 2. 4. The ice machine in kitchen was sanitized in accordance with manufacturer's guidelines. These failures had the potential to result in the spread of foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to follow it's policy and procedure on Advance Directive (AD - a written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them) for one of 36 sampled resident's (Resident 28). This failure had the potential to result in staff not providing to Resident 28 the appropriate treatment in the event of emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 36 sampled residents (Resident 23) significant change in status MDS (Minimum Data Set; Resident Assessment and Care Screening) was accurately completed for section K (Nutritional Status) when Resident 23 received nutrition care for a planned weight gain. This failure had the potential to result in an inaccurate MDS that could impede care planning to meet resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the head of bed (HOB) of one of 10 sampled residents (Resident 8) was elevated at least 30 degrees while receiving enteral tube (delivery of nutrition via a tube or catheter inserted directly into the stomach through the abdominal wall) feedings. This failure had the potential to result in aspiration (inhaling foreign substance such as food or liquid into the airway and lungs) and lung problems to Resident 8.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. One of 36 sampled residents (Resident 190) expired medication was disposed. 2. One of 36 sampled residents (Resident 138) medication was properly labeled with an expiration date. These failures had the potential for residents to receive expired medications which can adversely affect residents health condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow individualized meal tray ticket directions for one of 36 sampled residents (Resident 189) vegetables were not chopped. This failure had the potential to result in meal preferences not being honored.

Inspectors wroteBased on observation, interview, and record review the facility policy failed to address residents right to store outside food. This failure had the potential to not honor a resident and/ or families request to store food from the outside for later consumption.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures when two of two sampled Environmental Service Aides (EVS 1 and EVS 2) failed to ensure high touch surface areas (handrails, call lights, doorknobs, pull cords etc.) were properly disinfected daily. This failure had the potential to place residents, staff, and visitors at risk for the spread of infectious diseases.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the walk-in freezer in Kitchen 1 was maintained in good repair. This failure had the potential to result in compromised food quality and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 36 sampled residents (Resident 135 and Resident 140) empty vials of Heparin (a medicine used to decrease blood clots) were discarded in a designated waste bin. This failure had the potential to compromise the safety of residents, staff and visitors.