Maywood Skilled Nursing & Wellness Centre

Inspectors wroteBased on interview and record review, the facility failed to ensure safe transfer of one of three sampled residents (Resident 1) when Certified Nursing Assistant (CNA) 1 did not use a Hoyer lift (mechanical device used to safely lift and transfer non-weight bearing residents) to transfer Resident 1 from the shower chair to the bed. This deficient practice resulted in the unsafe transfer of Resident 1 and a displaced left femur fracture (a complete break in left thigh bone resulting in bone shift out of normal alignment). Resident 1 was transferred to the general acute care hospital (GACH) for evaluation and treatment and underwent an open reduction and internal fixation procedure (surgery performed to repair severe, displaced bone fractures).

Inspectors wroteBased on interview and record review, the facility failed to ensure the fall risk care plan included interventions for two-persons assist (method where two staff members move a resident who cannot bear weight or stand independently) and the use of a Hoyer lift (mechanical device used to safely lift and transfer non-weight bearing residents) with transfers for one of three sampled residents (Resident 1) . This deficient practice had the potential to place Resident 1's safety at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Office of the State Long-Term Care Ombudsman program (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) contact information was posted in a visible area to residents. This deficient practice had the potential to violate residents rights to file a complaint.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of 11 sampled residents (Resident 106, Resident 25, and Resident 4) received treatment and care in accordance with professional standards of care when:1. Licensed Vocational Nurse (LVN) 2 did not clarify Resident 106's order for cholecalciferol (also known as Vitamin D3, a vitamin essential for building and maintaining strong bones and immune function) and accurately document the omission on the Medication Administration Report (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident).2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure direct care staffing information [actual, hands-on hours worked by qualified staff such as registered nurses (RN), licensed vocational nurses (LVN) and certified nursing assistants (CNA) providing direct nursing services to residents] was submitted to the Centers for Medicaid Services (CMS- federal agency responsible for regulating healthcare quality). This deficient practice had the potential to place the facility at risk of unidentified staffing issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was readily accessible and within reach for one of six sampled residents (Resident 112). The call light was observed positioned behind the resident's bed, preventing immediate access. This deficient practice had the potential to significantly compromise Resident 112's safety by delaying Resident 112's ability to request assistance, thereby increasing the risk for unmet needs, injury, and adverse outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to notify one of one sampled resident's (Resident 91) physician of the resident's preference of taking Depakote Sprinkle (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] with small beads within a capsule that could be sprinkled onto soft food) capsules whole. This deficient practice had the potential to result in Resident 91 choking. Cross Reference F657 and F759.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' clothing and personal belongings were protected from view and potential loss when closet doors were left uncovered without doors or adequate protective measures for three out of six sampled residents (Resident 11, Resident 25, and Resident 116). This deficient practice had the potential to create a risk for theft and compromise the residents' sense of security and homelike environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the correct Preadmission Screening and Resident Review (PASRR- a federally mandated screening process designed to ensure individuals with serious mental illnesses or intellectual/development disabilities receive the necessary support) Level 1 Screening was received from the general acute care hospital (GACH) for one of three sampled residents' (Resident 12). This deficient practice resulted in the failure of a more in-depth Level 2 Mental Health Evaluation not being conducted and had the potential for Resident 12 to not receive the necessary and appropriate psychiatric level treatment and evaluation in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan was developed and implemented in a timely manner for three of six sampled residents (Resident 22, Resident 28, and Resident 4), who required the use of dentures and who was administered Haloperidol (an antipsychotic [a drug used for the treatment of symptoms of psychosis and other severe mental and emotional disorders]). This deficient practice had the potential to place Residents 22 and 28 at risk for impaired nutrition, oral discomfort, and difficulty with eating. This deficient practice also had the potential to place Resident 4 at risk for compromised mobility, social isolation, and pressure ulcer development (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence).

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise one of one sampled resident's (Resident 91) care plan to reflect Resident 91's preference of taking Depakote Sprinkle (an anticonvulsant medication, used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] with small beads within a capsule that could be sprinkled onto soft food) capsules whole. This deficient practice had the potential to result in Resident 91 choking. Cross Reference F580 and F759.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure one of three sampled residents (Resident 94) who was visually impaired was orientated to his meal tray during lunch time. This failure had the potential to put the resident at risk for serious physical harm (choking, aspiration, malnutrition, and/or burns) and negatively impacts their psychological well being, dignity, and independence

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their error rate was less than five percent (%) during the medication administration observation for two of five randomly selected residents (Residents 106 and 91). The outcome was four medication errors out of 27 opportunities for errors, which resulted in a medication administration error rate of 14.81%, based on the following:1. Resident 106 was given a multivitamin (dietary supplement containing a combination of essential vitamins) instead of multivitamin-minerals (multivitamin with minerals).2. Resident 106's cholecalciferol (also known as Vitamin D3, a vitamin essential for building and maintaining strong bones and immune function) was unnecessarily omitted and incorrectly documented.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper cleaning and sanitization of resident-use dining equipment, and properly label and store one of one resident's (Resident 54) food item brought in from the outside. These deficient practices had the potential to result in the use of improperly cleaned dishware and placed residents at risk for exposure to bacteria and contaminants, increasing the risk of foodborne illness, infection, and compromised health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Fall Risk Assessment was updated and accurately reflected the health status for two of 16 sampled residents (Resident 105 and Resident 82), and ensure the List of Residents with Special Needs and Resident Belongings List was updated to reflect upper and lower dentures were received for one of six sampled residents (Resident 28). These deficient practices had the potential to place Residents 105 and 82 at an increased risk for a fall, and resulted in the loss of Resident 28's dentures placing Resident 28 at risk for compromised nutritional intake due to impaired chewing ability, impaired communication, and increasing the potential for unmet needs and a decline in overall health and well-being.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure one of three sampled residents' (Resident 55) nasal cannula oxygen tubing and humidifier bottle were labeled with a date. This failure had the potential to increase the risk of infection of Resident 55.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food by methods that conserved temperatures when the lunch tray line food temperatures were as follows: 1. Quesadillas temperature measurement indicated 120 degrees Fahrenheit (°F, a degree of temperature). 2. Lasagna temperature measurement indicated 126°F . This deficient practice had the potential to place 112 of 115 facility residents who received food from the kitchen at risk of unplanned weight loss, a consequence of poor food intake from food in the kitchen. Cross reference to F812.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when food temperatures were out of range as follows: 1. Quesadillas measurement indicated 120 degrees Fahrenheit (°F, a degree of temperature). 2. Lasagna measurement indicated 126°F. This deficient practice had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (transfer of bacteria from one object to another) in 112 of 115 medically compromised residents who received food from the kitchen. Cross reference to F804.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the garbage storage area was maintained in a sanitary manner to prevent the harborage and feeding of pests when the outside trash dumpster lids were not closed. This deficient practice had the potential to result in creating harborage and feeding of pests which could lead to diseases and increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among facility residents.

Inspectors wroteBased on interview and record review, the facility failed to report abuse allegations to the State Agency (Department of Public Health), ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and the police department for two of 24 sampled residents (Residents 88 and 259) when: 1. Responsible Party (RP) 1 informed Registered Nurse (RN) 1 that Certified Nursing Assistant (CNA) 2 said hurtful things to Resident 88. 2. Resident 259 informed Licensed Vocational Nurse (LVN) 3 that CNA 2 had made him feel uncomfortable during a bed bath. These deficient practices resulted in a delay of an onsite inspection by the State Agency and had the potential for potential ongoing abuse. Cross Reference F610.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate abuse allegations and implement interventions to prevent further potential abuse for two of 24 sampled residents (Residents 88 and 259) when: 1. Responsible Party (RP) 1 informed Registered Nurse (RN) 1 that Certified Nursing Assistant (CNA) 2 had said hurtful things to Resident 88. 2. Resident 259 informed Licensed Vocational Nurse (LVN) 3 that CNA 2 made him feel uncomfortable during a bed bath. These deficient practices had the potential to result in unidentified abuse in the facility and failure to protect residents from further potential abuse. Cross Reference F609.

Inspectors wroteBased on interview and record review, the facility failed to respect the rights and provide dignity to two of six sampled residents (Resident 95 and Resident 75) by failing to: 1. Obtain a public guardian (a legally appointed person who manages the care and finances of individuals who are unable to do so for themselves) or conduct an interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) meeting to facilitate the care and medical treatments provided for Resident 75. 2. Follow its policy and procedure (P&P) titled Catheter - Care of, to provide a dignity bag (a bag used to cover and hold the catheter drainage/collection bag, so it is not visible) for Resident 95 who had both a left and right nephrostomy (a tube that lets urine drain from the kidney through an opening in the skin on the back) bag. [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain updated informed consents (a voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to the administration of psychotropic (medications that affect the mind, emotions, and behavior) medications for one out of six sampled residents (Resident 75). This failure had the potential to place Resident 75 at risk for avoidable harm from unwanted adverse effects (a harmful and undesired effect resulting from a medication or intervention) related to psychotropic medication use during the two months he was deemed to unable to make medical decisions. Cross Reference F550.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of one of 24 sampled residents' (Resident 259) abuse allegation when Resident 259 felt uncomfortable by Certified Nursing Assistant (CNA) 2 during a bed bath. This deficient practice resulted in Resident 259's physician being unaware of the abuse allegation and delayed any necessary care to be provided to Resident 259.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) for two of 24 sampled residents (Residents 88 and 259) by failing to: 1. Develop a care plan for Resident 88 after Responsible Party (RP) 1 informed Registered Nurse (RN) 1 that Certified Nursing Assistant (CNA) 2 said hurtful things to Resident 88. 2. Develop a care plan for Resident 259 after Resident 259 informed Licensed Vocational Nurse (LVN) 3 that CNA 2 had made him feel uncomfortable during a bed bath. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a communication device at the bedside for one of six residents (Resident 17) who had aphasia (a disorder that makes it difficult to speak). This deficient practice prevented Resident 17 from communicating effectively and had the potential to delay appropriate care and treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent the formation and/ or worsening of pressure ulcers/ injuries (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for three of three residents (Resident 15, 36, and 94) when the follow occurred: 1. Resident 15's low air loss mattress (LALM, a mattress designed to distribute body weight over a broad surface area to help prevent skin breakdown) did not reflect resident's weight on 12/16/2024. 2. Resident 36's LALM did not reflect resident's weight on 12/16/2024. 3. Resident 94's LALM did not reflect resident's weight on 12/16/2024. These deficient practices placed Resident 15, 36, and 94 at risk for worsening condition of their exiting pressure injuries, and/ or the development of new pressure injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Provide services to prevent the development of septic shock for one out of six sampled residents (Resident 259), who had long-term usage of an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) by failing to ensure the following:1a. Ensure Resident 259's the urinary drainage was monitored for the presence of sediment (a buildup of particles within the catheter tubing, often caused by factors like dehydration, urinary tract infection [UTI- an infection in the bladder/urinary tract], improper catheter care, or the presence of certain bacteria that promote crystal formation), abnormal color, and foul odor, per the facility's P&P and Resident 259's care plan, for a total of six months.1b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to check the gastrostomy tube (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) placement and gastric residual volume (GRV - the amount of liquid remaining in the stomach after an enteral feeding [method of feeding that uses the gastrointestinal [GI - stomach and intestines tract to deliver nutrition and calories]) for one of six residents (Resident 12). This deficient practice had the potential to cause aspiration (feeding entering the lungs), stomach irritation, vomiting, and malnutrition for Resident 12 .

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices for two of two resident (Resident 52 and 310) when the following occurred: 1. Resident 52's nebulizer mask (a plastic cup that fit over the mouth and nose to deliver liquid medication as a mist into the lungs) was unlabeled. 2. Resident 310's nebulizer mask was unlabeled. These deficient practices placed Resident 52 and Resident 310 at risk for infection which could increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive plan of care for one of three sampled residents (Resident 1) by failing to: 1. Develop a plan of care for a resident's known behavior of biting. 2. Develop a care plan for a resident at risk for elopement (when a resident leaves or wanders in a healthcare facility against medical advice). These failures resulted in Resident 1 wandering into Resident 2's room, hitting Resident 2 on the face, attempted to bite Resident 2 on the arm, and throwing a pitcher full of water on Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to closely monitor a resident with a known history of wandering, aggression, throwing items at staff, and biting for one out of three sampled residents (Resident 1). These failures resulted in Resident 1 wandering into Resident 2's room, hitting Resident 2's face, attempted to bite Resident 2's arm, and throw a pitcher full of water at Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to readmit one of three sampled residents (Resident 1) from the general acute care hospital (GACH) after Resident 1 was cleared by the GACH to return to the facility on 1/25/2024. This resulted in the denial of Resident 1 ' s right to return to the facility.

Inspectors wroteBased on interview and record review, the facility failed to distribute incoming mail on Saturdays for nine of nine residents (Residents 27, 32, 52, 55, 65, 74, 111, 116, and 119). This failure resulted in residents waiting an extra two days for their mail received by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respect and dignity to three residents out of 32 sampled residents (Resident 53, 84, 107) when: 1. A certified Nurse Attendant (CNA) answered Resident 53's call light from the hallway, screaming out loud to the resident and asking Resident 53 what he wanted. 2. Resident 84 alleged she was treated in a bad manner when the CNAs entered the resident's room to answer the call light. 3. Resident 107 felt disrespected by nursing staff. These deficient practices resulted in Residents 53, 84, and 107 to not be treated in a manner that did not promote and enhance a sense of well-being, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate the needs for one of 32 sampled residents (Resident 46), who had a diagnosis of dysphagia (difficult swallowing) and was at risk for aspiration (when food, drink, or foreign objects are breathed into the lungs), and by not ensuring the call light was within reach for two of 32 sampled residents (Resident 102 and 28) by: 1. Not providing Resident 46 with a proper functioning bed. The head of the resident's bed did not go higher than 25 degrees. 2. Not following the physician's order to raise the head of the bed to 30 to 45 degrees to prevent the resident from being short of breath. 3. Not placing Resident 102's and Resident 28's call light within reach. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document behavior monitoring on the Medication Administration Record (MAR) for one out of three residents (Resident 50). As a result, this deficient practice had the potential to affect the evaluation of psychiatric treatment and contribute to unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses followed their own Policy and Procedures (P&P) titled, Blood Pressure, when measuring one of four residents' (Resident 55) blood pressure (BP, the force of blood pushing against the walls of blood vessels). This failure placed Resident 55 at risk for incorrect blood pressure monitoring which could lead to adverse reactions, hospitalization, and/or death.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to assist a resident who is unable to carry out ADLs (activities of daily living) for one of 32 sampled residents (Resident 53) by: 1. Not providing oral care to Resident 53 in the last 3 consecutive days. 2. Not changing Resident 53's clothes in the last 3 consecutive days. 3. Not offering Resident 53 to get out of bed or to change his position for 3 consecutive days. 4. Not offering Resident 53 a shower on his scheduled shower day. 5. No cutting Resident 53 fingernails after the resident requested help. These deficient practices resulted in a negative impact on Resident 53's quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of two sampled residents (Resident 82) received a hearing aid to effectively communicate with staff. This failure had the potential to affect Resident 82's dignity, communication with staff, and prevent the resident's needs from being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for the removal of an intravenous catheter (IV; a soft, flexible tube placed inside a vein to administer medications or fluids) that was inserted more than 48 hours for one of one sampled resident (Resident 46). This deficient practice increased the risk for Resident 46 to develop complications and/or infection.

Inspectors wroteBased on interview and record review, the facility failed to accurately document controlled medications (medications that can cause physical and mental dependence) for one out of three sampled residents (Resident 50). This failure had the potential for Resident 50 to not receive the prescribed medication which would affect his wellbeing and increase potential for drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were properly stored and disposed of by: 1. Not following proper storing instructions of Humulin R insulin (a short-acting medication that starts to work 30 minutes after injection to treat high blood sugar also known as diabetes) for one out of three sampled residents (Resident 75). 2. Not abiding by its policy when disposing non-controlled medications by 2 licensed nurses. These failures had the potential to cause resident medications to be diverted (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber), misused, and can cause harm, hospitalization or even death to Resident 75 due of loss of medication efficacy (the ability for a medication to produce a desired or intended result).

Inspectors wroteBased on observation, interview, and record review, the facility failed to label one of 24 sampled residents' (Resident 369) peripheral intravenous line (IV; a soft, flexible tube placed inside a vein to administer medications or fluids) dressing with the date and time of insertion and the signature of the inserting nurse. This failure had the potential to result in Resident 369 developing an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report an abuse allegation within 2 hours for one of three residents (Resident 2). This deficient practice had the potential to result in additional harm to Resident 2 as evidenced by a bruise to the resident's left upper cheek (below the eye).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their Infection prevention and control policy and procedures (P&P) by failing to: a. Ensure staff doffed (removed) personal protective equipment ([PPE] specialized clothing or equipment such as a gown, respirator and face shield worn to minimize exposure to serious illness) prior to exiting a Coronavirus Disease ([Covid 19] a highly contagious respiratory infection caused by a virus that could easily spread from person to person) isolation room (designated room to separate sick resident with a contagious illness). b. Ensure nurses maintained short and well-trimmed fingernails. c. Report the facility's Covid-19 outbreak (at least one confirmed case of Covid-19 who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office. [...]