Marycrest Manor

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure for 43 of 44 medically compromised and vulnerable residents who received food from the kitchen: Ensure food items were labelled with opened and use by dates. Ensure dented cans were separated from useable stock and placed in specified labeled area. These failures had the potential to result in harmful bacteria growth and cross contamination (a transfer of harmful bacteria from one place to another or one object to another) that could lead to foodborne illness (an illness caused by food contaminated with bacteria, viruses, and other toxins).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had an alternative system of notification of lunch menu substitutions when an overhead page was not heard by three of three sampled residents. (Resident 4, Resident 23 and Resident 24). This deficient practice had the potential for residents to not be notified and substitutions and preferences to not be honored.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure therapeutic menu (meal plan that controls the intake of certain foods or nutrients) portion sizes were followed for 43 of 44 medically compromised and vulnerable residents who received food from the kitchen. This deficient practice had the potential to place residents at risk for not having nutritional needs met and potential weight gain.

Inspectors wroteBased on interview and record review, the facility failed to:1. Submit and transmit the Minimum Data Set ([MDS] - a resident assessment tool) within the regulatory timeframe to the Center for Medicare and Medicaid Service (CMS) for one of 12 sampled residents (Resident 3). This deficient practice had the potential to result in billing error and inaccurate data on resident care needs.

Inspectors wroteBased on interview and record, the facility failed to ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of 12 sampled residents (Resident 14) by failing to:1. Ensure Resident 14's Plavix (classified as antiplatelet agent drug used to prevent blood clots) was not encoded as anticoagulant (blood thinner) medication. This failure resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 14.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan for two of 12 sampled residents (Residents 5 and 14) by failing to:Address Resident 5's diagnosis of schizophrenia (a mental illness that is characterized by disturbance in thought). Address Resident 14's allergy to aspirin (drug used to reduce pain, fever, and prevent blood clot). This deficient practice had the potential to result in a lack of meeting necessary care and addressing medical needs for Resident 5 and Resident 14.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 7)'s mouth was rinsed after administration of prescribed inhaler Arnuity Ellipta [an inhaler used as a maintenance medication for asthma (a condition that causes the respiratory airways to swell up, shrink, and fill with mucus)]. This failure had the potential to result in Resident 7's developing irritation of the mouth, discomfort, and an increased risk of infection of the mouth and throat due to medication remaining in the mouth after inhaler use.

Inspectors wroteBased on interview and record review, the facility failed to:1. Document the medical appointment for one of one sampled resident (Resident 14). This deficient practice had the potential to place Resident 14 of not receiving appropriate care and delay in communication among staff due to incomplete medical records.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Maintain and notify the dietary supervisor of the temperature being out of range in one of the walk-in refrigerators during the month of February. This deficient practice had the potential for food spoilage and can cause foodborne pathogens in the residents.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure an accurate Minimum Data Set ([MDS] - a resident assessment tool) was completed accurately for one of 12 sampled residents (Resident 18) by failing to: 1. Ensure Resident 18's Depakote (an anticonvulsant used to treat seizure disorder and other psychiatric conditions) medication was encoded as anticonvulsant and reflected in the MDS assessment under Section N (N0415 High-Risk Drug Classes) medication. This deficient practice resulted in incorrect data transmitted to Center for Medicare and Medicaid Services (CMS) related to inappropriate MDS care screening and assessment tool practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one out of 12 sampled residents (Resident 28) had four padded side rails on the bed per physician's order. This deficient practice had the potential to result in Resident 28 being injured in the event of a seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness)

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure one out of 12 sampled residents (Resident 28) was not prescribed Seroquel (an anti-psychotic medication used to treat mental illness) to control dementia (condition where there is a decline in mental abilities and memory) symptoms. This deficient practice put Resident 28 at risk of an adverse reaction (bad outcome) from taking an anti-psychotic without a diagnosis of a mental illness.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure laboratory test (a medical procedure that analyzes a sample of blood, urine, or other bodily fluid or tissue) was completed as ordered by the physician for one of 12 sampled residents (Resident 18). This deficient practice had the potential for Resident 18 not receiving necessary medical treatment.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure the quarterly Minimum Data Set ([MDS], a standardized assessment and care planning tool) was submitted to Centers for Medicare and Medicaid Services (CMS) within 14days after completion for three of three sampled residents (Residents 9, 11, and 25) This deficient practice resulted in data not being transmitted to CMS regarding resident's current assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were labeled and expired food was discarded in a sanitary manner to prevent growth of microorganisms that could cause food borne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food) for 43 out of the 46 residents in the facility by failing to: 1. Ensuring 10 packs of frozen vegetables in Freezer 1, 2 opened 1-gallon milk cartons, a storage bin of lemons and green onions in Refrigerator 2, and [NAME] and Basmati [NAME] stored in the dry storage room were labeled. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure proper infection control techniques were performed during wound care treatment for two of two sampled residents (Resident 26 and Resident 9). This deficient practice had the potential to result in contamination of the residents' wounds and placed the residents at risk for infection.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure a change of condition Preadmission Screening & Resident Review (PASARR) was submitted to the Department of Health Care Services (DHCS) to ensure the resident was re-evaluated for one of one sampled resident (Resident 40) This deficient practice had the potential to cause harm due to not receiving care and services in the most appropriate setting for the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Provide pharmaceutical services that met the needs one of six sampled residents (Resident 101). Resident 101 did not receive medication at the scheduled time and with food as ordered by the physician. This deficient practice had the potential for avoidable physical harm related to residents not receiving their medications on time, or experiencing potential adverse drug reactions from medications being administered differently from how they were ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure a two multi-dose vials of heparin were labeled with the dates when the vials were opened. These deficient practices had the potential for unintentional medication administration of possibly expired medication for the residents.