Redwood Terrace Health Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a restraint was re-evaluated for one of one sampled resident (Resident 5) reviewed for physical restraint. This failure had the potential for Resident 5 to be restrained unnecessarily. Cross Reference F 636.

Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold notice to the resident and or resident's Responsible Party (RP - an individual authorized by the resident to act as an official representative) upon transfer to the hospital for one of two residents (Resident 4) reviewed for hospitalization. This failure had the potential for Resident 4 and his RP being unaware of the bed hold duration and his right to return to the facility after hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and document the use of hand mittens for one of one sampled resident (Resident 5) reviewed for physical restraint. This failure had the potential for Resident 5 to be restrained unnecessarily. Cross Reference F 604.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice when a Licensed Nurse (LN) did not follow physician's order/instructions during medication administration observation. This failure had the potential to cause side effects for Resident 38's health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and nutrition services staff was knowledgeable to safely and effectively carry out the functions of the department, when one [NAME] (CK 1) incorrectly demonstrated how to calibrate a food thermometer. This failure in staff competence could lead to incorrect food temperature, which could increase the risk of foodborne illness in the resident population of 47.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when a Dietary Aide (DA) 2 was not wearing a hair net while sorting the food utensils in the food cart. This finding had the potential for food contamination and exposed the facility's residents to unsafe and unsanitary food practices that could lead to widespread food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own policy or guidance regarding Enhanced Barrier Precautions (EBP- an infection control strategy that uses gown and gloves during high contact resident care like medication administration to residents with pressure ulcer [injury to the skin and underlying tissue]), when a licensed nurse entered an EBP room without performing hand hygiene (handwashing or alcohol based handrub) and donning personal protective equipment (PPE-such as the use of gloves, gown, mask). As a result, there was a potential for cross contamination and spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to send the results of an alleged staff to resident (Resident 1) abuse investigation to the State agency (California Department of Public Health, CDPH-licensing and certification agency) within five working days. This deficient practice had the potential for residents to not be protected from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure LN removed an expired medication from the medication cart for one of two medication carts observed. In addition, LN left medications unattended in residents room and allowing residents to self-administer without proper assessment and qualification for two of 13 sampled residents (27 and 88), and five unsampled residents (16, 30, 32, 194 and 200). As a result, there was a potential for staff to administer expired medication. In addition, staff would not have been able to verify the appropriate dose taken by the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure restorative nursing (care to improve or maintain the functional ability of the resident) was conducted per the physician's order for one of seven sampled residents reviewed for limited mobility (7). As a result, there was a potential for Resident 7 to experience a decrease in mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food stored and prepared in the kitchen was in accordance with professional standards for food and service safety when: 1. the walk-in refrigerator had open and undated food, and 2. a box of lemon-glycerin swabsticks (lemon-flavored medical swab sticks that were 4-inch plastic swabs with [NAME] or foam tips) was stored in the residents' reach-in freezer. As a result, there was a potential for the staff to serve contaminated or spoiled food, and swabsticks may accidentally be ingested by a confused resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control prevention for one of 13 sampled residents (28) when the LN put on new gloves without performing hand hygiene. As a result, there was a potential for cross-contamination.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan for Resident 22's actual weight loss. This failure had the potential for Resident 22 to not receive person-centered care for their weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two residents (Res38), low air loss mattress (a medical air mattress used to prevent skin breakdown) was properly set up. This failure had the potential to cause Resident 38's pressure ulcer (skin injury which developed because of pressure over a bony area of the body) to worsen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing data was posted in a prominent place accessible to residents and visitors to include: total number of actual hours worked by nursing staff (Registered Nurses, Licensed Vocational Nurses, Certified nurse aides) & resident census. This failure had the potential to result in residents and visitors having to ask the facility for their staffing information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired medical supplies and specimen tubes (used to collect samples for medical testing) from one of one medication storage room. In addition, the facility failed to assess for the ability to self-medicate and obtain a physician's order to keep medications at the bedside for one of two residents (8 ) reviewed for self - administration of medications. This failure had the potential: 1. to affect the test results for the use of expired medical supplies, and; 2. to place Resident 8 at risk not to take their prescribed medication and gave other residents access to the medications left at the bedside.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's personal information was protected, when an empty medication bubble pack for one unsampled resident (25) was left on top of a medication cart. This failure had the potential for the resident's information to be viewed by anyone who passed by the cart.