Petaluma Post-Acute Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of two residents (Resident 36 and Resident 92) had access to devices needed for sensory impairment when,1. Resident 36 reported broken glasses, needed for distance, on admission, and the glasses remained unaddressed a month later. And,2. Resident 92 reported needing hearing aids to hear people clearly, on admission, and Social Services did not respond to his request. This failure affected both residents' ability to actively engage in their care, their overall functionality, and their sense of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication labeling and storage practices were followed when,1. A loose Lantus Solostar Insulin Pen (A disposable prefilled injection device for long-acting insulin administration for diabetic residents) was found in the medication refrigerator with no label, no resident name, no instructions, no open date. And,2. Medication tablets and pills intended for wasting, were collected and filled in an unlabeled urine specimen cup that was stored inside a medication cart. These failures had the potential to contribute to unsafe medication use and administration and medication diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control procedures were followed for two of two Residents (Resident 62 and Resident 64), when Licensed Nurse 1(LN 1) did not disinfect the blood pressure cuff between use on these residents. This failure had the potential to spread infection between residents.

Inspectors wroteThe facility failed to ensure the Ombudsman (A government official who advocates for residents directly with the facility to resolve concerns and complaints) was notified, when one Resident (Sampled Resident #83) was transferred to the hospital. This failure had the potential to deny protection to Resident #83 from being inappropriately transferred or discharged and to have access to an advocate who could inform them of their options and rights.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement an effective discharge planning process for one resident (Resident 1) of three sampled residents when Resident 1 and his family member were not trained on how to administer Resident 1's enteral nutrition formula (liquid nutrition) using Resident 1's gastrostomy tube (G-tube, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and Resident 1's feeding pump (used to deliver the enteral nutrition) had not been delivered to Resident 1's residence upon his discharge. [...]

Inspectors wroteBased on observation, interview, record review, facility policy review, the facility failed to complete an assessment to determine if a resident was able to self-administer their medication(s) for 1 (Resident #52) of 18 sampled residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff wore a gown and gloves when they provided incontinence care to 2 (Resident #34 and Resident #66) of 18 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents could receive visitors outside of regular working hours for one (Resident 64) of 17 sampled residents. This failure did not ensure Resident 64's rights, and had the potential to negatively affect residents' psychosocial outcomes due to restricted visitation of families and friends who may want to visit and cheer-up residents in the morning or evening, outside of business hours.

Inspectors wroteBased upon observation, interview and record review the facility failed to provide individualized activities for three of 17 sampled residents (Resident 43, 58, and 64). This deficient practice had the potential to affect the quality of life of residents by placing them at risk of sensory deprivation and decreased cognitive functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the Infection Control Policy for 2 of 17 residents (Residents 14 and 33) when: 1. The Infection Preventionist (IP) did not perform hand hygiene between concluding a wound care and treatment for one resident (Resident 14) and touching doorknobs inside the resident's room. In 7/2021, Resident 14's wound became colonized with an infection caused Methicillin-resistant Staphylococcus aureus (MRSA, a strain of bacteria resistant to certain antibiotics and spread by contact with infected people, surfaces, or things that carry the bacteria); 2. Resident 33 exhibited potential symptoms of C. Diff. (a healthcare-associated infection causing loose stools) but the facility delayed implementation of its infection surveillance policy. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to care plan (care plans provide communication among nurses, their residents and other healthcare providers to achieve health care outcomes) its continued use of a position change alarm (an audible alarm that alerts staff the resident is getting up, and that should be used only when medically necessary and with intermittent reevaluation for continued use) for for 1 of 17 sampled residents (Resident 28). Resident 28 was known to remove the clip connected to the alarm. The failure to care plan resulted in the position change alarm constantly in use, and had the potential to diminish Resident 28's psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to revise a care plan with updated interventions for one (Resident 64) of 17 sampled residents, when facility staff reviewed the nutritional care plan but did not document new interventions to manage resident 64's continued weight loss. This failure resulted in Resident 64 suffering significant weight loss within one month.

Inspectors wroteBased on interview and record review, the facility failed to adopt a discharge care plan that identified nutritional needs for one (Resident 64) of 17 sampled residents, when the facility's discharge plan for Resident 64 did not address weight loss and how to stabilize or gain weight. This failure had the potential to cause Resident 64 further weight loss and fatigue.

Inspectors wroteBased on observation, interview and record review the facility failed maintain acceptable nutrition for one (Resident 64) of 17 sampled residents. This resulted in Resident 64 suffering a significant weight loss within one month of admission, which effected her overall health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary behavioral health care and services for 1 out of 17 residents (Resident 50), when facility staff failed to facilitate the resident's referral for psychological services and evaluation. This failure resulted on Resident 50 showing increased anxious behavior and receiving a new medication to address her anxiety, and did not ensure services to attain or maintain the highest practicable physical, mental, and psychosocial well-being

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the drug regimen for one of 17 residents (Resident 33) was free from unnecessary drugs, when facility staff administered laxitive medication to Resident 33 when the resident had loose bowel movements, contrary to physician order. This failure resulted in Resident 33 receiving medication that was not clinically indicated, which had the potential to cause unnecessary discomfort and stress to the gastrointestinal (GI) tract, and delay diagnosis for the cause of the GI resident's distress.