San Francisco Health Care

Inspectors wroteBased on interview, and record review, the facility failed to ensure Resident 2 was free from physical restraints when Certified Nursing Assistant (CNA) 1 used a sheet to restrict Resident 2's movement. This failure had the likelihood to result in physical harm, pain, fear, and loss of autonomy for Resident 2. Additionally, this incident was not documented in Resident 2's electronic medical records. There was no documented evidence Resident 2's emergency contacts or her physician were notified of the incident. There was no documented evidence Resident was monitored and provided psychosocial care after the incident.

Inspectors wroteBased on interview and record review, the facility failed to re-admit Resident 1 after sending Resident 1 to a hospital for evaluation. This failure deprived Resident 1 of his right to return to the facility and resume necessary care and services identified in the resident's care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to inventory and secure personal properties for Residents 1, 2, 3, and 4. These failures resulted in missing properties for Residents 1 and 2 and inaccurate and/or missing inventory lists for Residents 3 and 4.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of misappropriation of personal properties for Residents 1 and 2 within 24 hours to the appropriate agencies. This failure did not ensure vulnerable residents were protected from misappropriation of personal properties.

Inspectors wroteBased on interview and record review, the facility failed to investigate allegations of misappropriation of personal properties for Residents 1 and 2. This failure did not ensure the facility could uncover weaknesses within their system to safeguard personal properties or implement effective measures to prevent misappropriation of personal properties.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify environmental hazards, implement interventions, and maintain assistive device (refers to any item including wheelchair and walker, that is used by, or in the care of a resident to promote, supplement, or enhance the resident's function and/or safety) in good working condition for two of 22 sampled residents (Resident 25 and Resident 73) when: 1. A fall mat was placed on the floor between Resident 25 in bed A and his roommate in bed B obstructing the path and safe passage. As a result, Resident 25 tripped, fell onto the floor and sustained a right hip fracture requiring surgical repair. [...]

Inspectors wroteBased on observation, interview, and record review, for Residents 3, one of two residents with weight loss out of a total sample of 22 residents, the facility did not: 1. Provide 1:1 assistance/support during meals as ordered by the physician. 2. Monitor percentage of supplement eaten. 3. Offered alternatives/other interventions during poor meal intake. 4. Implement a meal monitoring system that could distinguish between 0-25% intake for residents at risk for poor intake. 5. Use meal intake data to investigate refusals, assess food preferences, and/or identify other issues. 6. Assess for food preferences. This resulted in a 24.4% weight loss for Resident 3 within a six months period.

Inspectors wroteMedication Error rate- 25.9% Based on observation, interviews and record review, the facility had a medication error rate of 25.9% when seven medication errors occurred out of 27 opportunities during the medication administration for four of seven residents (Residents 256, 72, 63 and 17). The failure had the potential to result in residents not receiving full therapeutic effects or causing side effects for the residents.

Inspectors wroteBased on observation, interview and record review the facility failed to prepare, store, and serve food in a sanitary manner when these were observed in the kitchen and other areas: 1. One of the icemaker's dispensing spouts was dripping water. 2. The ice maker had two water filters and one of the water filters was not replaced. 3. The bottom of the kitchen hood was covered in a film of a greasy-looking substance. These failures had the potential to result in putting residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of kitchen refuse properly when two garbage containers within the kitchen did not have lids. This failure had the potential to result in flying insects contaminating food items, food prep areas and utensils.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection control program when enhanced barrier precautions (EBP) was not followed for four of 11 residents (Resident 62, Resident 204, Resident 25, Resident 256) with indwelling medical devices. This failure has the potential to result in cross contamination of infection which may jeopardize the health and safety of the residents and staff. Definition: Enhanced Barrier Precautions (EBP) - refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Indwelling medical devices - refers to a device that is inserted into the body and remains there for a period of time, such as central lines, urinary catheters, and feeding tubes. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program, when flying insects were seen in the facility. This failure had the potential to result in exposing residents to pest borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was covered with a privacy bag for one of 6 residents with indwelling catheters (Resident 25). This failure had the potential to affect Resident 25's psychosocial (mental, emotional, social, and spiritual effects) well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure baseline care plan was developed within 48 hours of admission for one of 22 sampled residents (Resident 204). This failure had the potential to result in inadequate care and services rendered to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a plan of care for one of 22 sampled residents (Resident 25) who fell and fractured his hip. This failure resulted in Resident 25 not receiving the necessary care and treatment such as physical and occupational therapy. Additionally, this resulted in miscommunication between the staff and Resident 25 regarding aftercare and weight bearing activities.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a coordinated plan of care and communication process with the Hospice agency, when there was no care plan to address what services Hospice will provide and for facility when to notify Hospice for one (Resident 61) of two sampled residents. This failure had the potential to result in hospice residents being at risk for gaps in their hospice services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide specialized rehabilitative services (includes but is not limited to physical therapy, speech-language pathology, occupational therapy, or respiratory therapy and are provided or arranged for by the nursing home) for one of 22 sampled residents (Resident 25) that required physical therapy (PT-treatment that helps you improve how your body performs physical movements) and occupational therapy (OT-a healthcare profession that focuses on helping individuals improve their ability to perform everyday activities) status post (s/p-a medical or clinical shorthand that refers to a state after an intervention) right hip hemiarthroplasty (a surgical procedure that replaces the femoral head (ball) of the right hip joint with an artificial implant). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate discharge for one of 3 sampled residents (Resident 1) when there was no evidence of discharge basis and discharge summary for Resident 1 regarding his discharge on [DATE]. This failure could result in an inappropriate discharge that may disrupt the provision of care for Resident 1.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to implement measures to prevent Resident #76 from having unsupervised access to smoking materials, including lighters, cigarettes, and marijuana. This failure affected 1 (Resident #76) of 5 total residents identified by the facility as smokers. The facility allowed Resident #76 to have unsupervised visits with Visitor #28, who repeatedly provided the resident with smoking materials despite having been educated on the facility's smoking policies multiple times. After the facility had educated both Resident #76 and Visitor #28 on the facility's smoking policies, the resident and visitor continued to be noncompliant. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure that 4 of 4 resident shower rooms were maintained in a clean and homelike condition.

Inspectors wroteBased on interviews, facility document review, and facility policy review, the facility failed to ensure they completed a facility-specific risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. This failure had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure comprehensive care plans reflected all care needs for 1 (Resident #400) of 2 sampled residents reviewed for hospice services, 1 (Resident #15) of 1 sampled resident reviewed for clothing preferences, 1 (Resident #86) of 1 sampled resident reviewed for behavioral needs, and 1 (Resident #49) of 1 sampled resident reviewed for an indwelling urinary catheter. Specifically, the facility failed to ensure: 1. Resident #400's comprehensive care plan accurately reflected the resident's current hospice provider and contact information; 2. Resident #15's comprehensive care plan reflected the resident's preference to wear a hospital gown instead of personal clothing; 3. Resident #86's comprehensive care plan identified the resident's documented behaviors and directed staff how to respond; and 4. [...]

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure each resident's electronic health record (EHR) and physical medical chart accurately and consistently reflected their treatment wishes, including their decision regarding cardiopulmonary resuscitation (CPR), for 3 (Residents #39, #12, and #92) of 13 sampled residents reviewed for advance directives. Specifically, the facility failed to ensure residents' orders regarding code status (guidance to medical providers regarding the resuscitation efforts one would like to receive in the event they were found in cardiac arrest or not breathing), physical medical chart, and visual indicator on their chart all matched and reflected the resident's treatment wishes as directed by their current Physician Orders for Life Sustaining Treatment (POLST).

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure 2 (Resident #301 and Resident #11) of 2 sampled residents reviewed for privacy were provided personal privacy during the provision of showers.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to include a diagnosis of a major mental illness on a Preadmission Screening and Resident Review (PASRR) Level I for 1 (Resident #26) of 2 sampled residents reviewed for PASRR screenings.

Inspectors wroteBased on observation, interviews, record review, facility policy review, and Centers for Disease Control and Prevention (CDC) guidelines, the facility failed to ensure services provided met professional standards of quality for 1 (Resident #50) of 1 resident reviewed for an intramuscular injection. Specifically, Registered Nurse (RN) #3 prepared an intramuscular injection by reconstituting the medication and then used the same needle to administer the medication to the resident. Furthermore, RN #3 stuck the resident with the needle, removed the needle prior to administering the medication, then re-stuck the resident with the same needle and administered the medication.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure that 1 (Resident #49) of 2 sampled residents reviewed for tube feedings received appropriate treatment and services to prevent potential complications. Specifically, staff failed to check the placement of Resident #49's feeding tube prior to the administration of water flushes and medications in accordance with a physician's order and the facility's policy. In addition, staff administered Resident #49's water flushes and medications dissolved in water by utilizing the plunger of a syringe to push them into the resident's feeding tube instead of administering them by gravity flow as directed by the facility's policy.

Inspectors wroteBased on observations, interviews, record reviews, and facility policy review, the facility failed to ensure the medication error rate was not greater than 5 percent (%). There were 2 errors out of 34 opportunities, resulting in a medication error rate of 5.8%, affecting 1 (Resident #50) of 10 residents observed during medication administration.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure all drugs and biologicals were secured and accessible by only licensed personnel for 1 of 4 medication carts observed. Specifically, Registered Nurse (RN) #3 left the medication cart unlocked and not within their line of sight, with medications lying on top of the cart unsecured.

Inspectors wroteBased on observations, interviews, facility document review, and facility policy review, the facility failed to maintain an effective pest control program so that the facility was free of pests, which affected 1 (Resident #76) of 21 sampled residents.

Inspectors wroteBased on observation, interview and record review, the facility had 20.69% error rate when six medication errors out of 29 opportunities were observed during a medication pass for Resident 36, Resident 94, Resident 48, and Resident 31. These failures resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications which may result in the residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on dietary services observation, dietary staff interview, and dietary document review, the facility failed to ensure dietetic services were implemented in accordance with acceptable standards of practice when: 1. Yogurt with temperature of 48 degrees was found sitting on the night stand for Resident 246. 2. Milk was found sitting on the overhead table for more than four hours for Residents 246, 78, 32, 90 and 57. Failure to ensure safe and sanitary food handling practices had the potential to subject residents to foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its infection prevention and control program when: 1. Registered Nurse (RN) 3 did not disinfect the glucometer in between patient use. 2. Staff did not used the appropriate disinfectant product on resident care equipment; 3. Used suction canister and yankuer tip catheter were unlabeled and undated; 4. Staff food was found on the residents overbed table. This facility failure has the potential to spread infection to residents and staff. Definitions: Disinfectant: usually a chemical agent (but sometimes a physical agent) that destroys disease-causing pathogens or other harmful microorganisms but might not kill bacterial spores. It refers to substances applied to inanimate objects. Disinfection: thermal or chemical destruction of pathogenic and other types of microorganisms. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan that included measurable objectives and timetables for one of 21 sampled residents (Resident 64) when care plan did not indicate the specific target behavior for the use of Seroquel (an antipsychotic medication). This deficient practice had the potential to negatively impact Resident 64's quality of life as well as the quality of care and services received.

Inspectors wroteBased on observation, interview and record review, the facility did not provide pharmacy services to Resident 36 when correct Vitamin D dose was not available for use according to her physician's orders (also See F759). These failures resulted in medications not given in accordance with the prescriber's orders which may result in the residents not receiving the full therapeutic effect of the medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe storage of medications when: 1. Resident 246's insulin was stored with rectal suppositories on 3rd floor medication cart. 2. Resident 246's nystatin powder medication was being kept and placed on top of his bedside table. This deficient practice could lead to contamination of medication; and failure to secure medications in a locked storage could lead to unwanted residents accessing and ingesting medications that could lead to clinically significant adverse consequences.