San Jacinto Valley Post Acute

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the attending physician timely of a low potassium level for one of three residents (Resident 1). This failure resulted in Resident 1's transfer to the acute hospital for treatment had the potential for the resident to sustain a cardiac arrest (an electrical malfunction that causes the heart to suddenly stop beating effectively, halting blood flow to the brain and vital organs) or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an exit door (EXD 1), located along (name of street), was readily accessible and unobstructed for 24 of 24 residents when the door handles were secured with a zip tie. This failure resulted in an obstructed exit door and had the potential to result in a delay or prevent the residents from exiting the facility during an emergency, such as a fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement, review, and re-evaluate care plan interventions to prevent falls two of 19 residents reviewed (Resident 20 and Resident 86). This failure resulted in Resident 20 and Resident 86 experiencing multiple falls and had the potential for Resident 20 and Resident 86 to sustain avoidable injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure provision of safe and effective pharmaceutical services to meet the needs of the residents when: Medications with holding parameters were not administered according to the physician's orders for three of four reviewed residents (Resident 2, 3, and 109) on blood pressure (BP) medications. This failure had the potential to significantly lower blood pressure to cause dizziness, confusion, fainting and a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage of medications in accordance with the facility policy and procedures (P&P) and manufacturer's specifications when: 1. One expired house supply medication (medications kept for general use for residents, rather than dispensed or labeled for a specific resident) was stored in one of two reviewed medication rooms (North Medication Room); and2. An expired medication was kept in stock in one of five reviewed medication carts (Middle Medication Cart) along with other active medications. These failures had the potential for the residents to receive expired or ineffective medications, which could lead to medication errors and compromised treatment outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items readily available for use were stored in the freezer with a label of open date or expiration date. This failure had the potential to result in foodborne illness to a vulnerable facility population.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Residents 3 and 105) reviewed for unnecessary psychotropic (drug that affects brain activities associated with mental processes and behaviors) medications were free from unnecessary psychotropic medications when: 1. For Resident 3, Mirtazapine (Antidepressant medication used to treat depression) was prescribed with an indication of Depression without physician-documented clinical evidence supporting a diagnosis of depression; and 2. For Resident 105, the physician did not document the clinical rationale for continued use of the as-needed temazepam (a psychotropic medication used for inability to fall asleep) beyond 14 days. This failure had the potential to result in unnecessary use of psychotropic medications, and increased risk for adverse effects, including falls or sedation.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess one of 19 residents (Resident 14) reviewed for Minimum Data Set (MDS - an assessment tool) to reflect the resident's status when Resident 14's MDS assessment had a diagnosis of schizophrenia (a mental illness characterized by disturbances in thought process) without a psychiatric evaluation. This failure had the potential for Resident 14 to receive inappropriate care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents reviewed (Resident 2) was free of unnecessary medications, when pain assessments were not consistently implemented and documented in conjunction with the administration of scheduled narcotic pain medication. This failure resulted in unmonitored medical condition and had the potential for ineffective pain management, unnecessary excessive dosing, and adverse effects for Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a safe discharge for one of three sampled residents (Resident 1), who uses a wheelchair and required partial to moderate assistance with mobility and ADLs (Activities of Daily Living-basic self-care task such as bathing, dressing, toileting, getting in and out of bed), when the facility failed to assess the resident for appropriate discharge placement. The resident was discharged to a two-story room and board without personal care assistance and was given a bedroom on the second floor. The facility also failed to verify and ensure the receiving facility could meet the resident's care needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a system of safeguarding personal belongings, such as bank card and Identification (ID) card, were in place, for one of three residents reviewed (Resident 1). This failure resulted to unauthorized bank transactions on Resident 1's bank cards while at the facility without her knowledge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of two residents, Resident 1, a medication ordered by the doctor was given as prescribed. This failure had the potential for Resident 1 to have hypokalemia (low potassium level in the blood) which could cause Resident 1 to experience muscle cramps and abnormal heart rhythms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention protocols were implemented, for two of two residents, Residents 1 and 2, when a facility staff member did not perform hand hygiene in between residents ' care, and did not disinfect the automatic blood pressure cuff (BP cuff) before and after residents ' use. These failures had the potential for the vulnerable residents to be exposed to cross-contamination and the development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of four residents reviewed for urinary catheter (tube inserted into the bladder to drain urine), the urinary catheter drainage bag was covered with a dignity bag (a bag that covers and holds a catheter drainage to keep it out of sight). This failure resulted in violation of Resident 37's rights to be treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan for the care of resident's surgical site and left hip dressing was initiated and developed for one of 19 residents reviewed (Resident 141). This failure had the potential for Resident 141 not to receive the necessary care and services if the surgical site developed infection and/or the resident experienced other complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice for two (Residents 45 and 12) of 19 residents reviewed, when: 1. For Resident 45, one opened tube of Voltaren cream (medication used to treat arthritis pain) and one opened bottle of Magnesium Ashwagandha tablets (a medication that supports mental health and sleep) were observed on top of the resident's bedside table; and 2. For Resident 12, one opened bottle of Calcium Carbonate (medication used to relieve heartburn, acid indigestion, and stomach upset) was observed on top of the resident's bedside table. These failures had the potential for Residents 45 and 12 to receive medications without a physician's order.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one of 19 residents (Resident 66) reviewed who smoked in the facility did not have a lighter in her possession. This failure had the potential to result in injury or accident related to unsupervised smoking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to an already vulnerable facility population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were implemented for three of 19 residents reviewed (Residents 69, 86, and 140) when: 1. For Resident 69, the hand held nebulizer mouthpiece (a device that contains medication that turns into a mist) was left exposed on top of the bedside table near the resident's urinal; 2. For Resident 86, the Enhanced Barrier Precaution (EBP - infection control practices that use gowns and gloves to reduce the spread of multidrug-resistant organisms) was not followed when the resident was admitted with the colostomy (an operation in which a piece of the colon is diverted to an artificial opening in the abdomen that allows stool to pass through); and 3. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure the resident's representative was informed of an incident of fall for one of six resident reviewed (Resident C). This failure has the potential to result in the resident's representative to be unaware of the resident's condition which could delay the involvement of the representative in planning the care for their family member (Resident C).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (Resident D) of four residents reviewed for pressure ulcers/injuries (PU/PI-localized damage to the skin and underlying soft tissue usually over a bony prominence resulting from intense or prolonged pressure), received care and services consistent with professional standards of practice, when the status of the pressure injuries, which included measurements, were not consistently documented. In addition, the facility failed to ensure provision of wound treatment was coordinated with the wound care team. These failures have the potential to result in inconsistent provision of wound treatment which could contribute to the delayed healing of the resident's pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was transferred with two person assist using the Hoyer lift (a portable total patient lifting tool to assist in transferring patients in and out of bed), from his Geri-chair (a large padded chair that can recline and is used for people with limited mobility), to bed. This failure had the potential to result in an injury to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety requirements for food storage and preparation were followed when: - Multiple food items stored in the dry storage area and refrigerator were not labeled with the opened date, or use-by date, and expired food was available for resident use; - Thawing meat in the refrigerator was not labeled with the start and end date of thawing; - The facility log for the dish machine (dish washer) temperatures were not documented for 14 out of 79 entries; and - Two of the five kitchen food carts (large carts used to transport resident food to the floor for meal service) were observed with peeling duct tape. These failures had the potential to place the residents of the facility at risk for food-borne illness in a medically vulnerable resident population who consumed food in the facility. Facility census was 95.

Inspectors wroteBased on interview, and record review, the facility failed to ensure, for one of eight residents reviewed (Resident 3), professional standards of practice were followed when the facility practice for hospice services (focused care for end-of-life) evaluation was not conducted prior to the resident ' s discharge with hospice services. This failure had the potential for Resident 3 ' s family to not fully understand hospices services, and to potentially experience emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure discharge planning activities were conducted and documented for one of two residents reviewed (Resident 4). This failure had the potential to result for a delay in achieving Resident 4 ' s discharge goal.

Inspectors wroteBased on observation, interview, and record review the faciity failed to provide quality of care when: 1. The facility failed to ensure a change of condition (COC) was completed, monitoring done, and the care plan updated and/or revised for two of eight residents reviewed (Resident 1 and 2), when Resident 1 and 2 appeared to be intoxicated on December 14, 2023. This failure had the potential to result in Resident 1 and 2 to not be adequately monitored for safety risks, and possible medication(s) interactions. 2. The facility failed to accommodate the need for one of one resident, Resident 5, when a bariatric chair (specialized seating) was not available for his use. This failure had the potential for Resident 5 to be at risk for further decline in mobility.

Inspectors wroteBased on interview and record review the facility failed to ensure that the restorative nurse assistant (RNA) exercises were provided for two of three sampled residents, Resident 4 and 5 when: 1. Rehabilitation therapists ' recommendations for Resident 4 were not communicated to the nursing department and the RNA. 2. Resident 5 did not receive RNA exercises on January 15 and 31, 2024 and February 1, 2, 5 and 7, 2024. These failures had the potential for Resident 4 and 5 to have a decline of range of motion. On February 8, 2024, at 10:26 a.m., an unannounced visit was conducted to the facility for an investigation of three complaints.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment for one of three sampled residents (Resident 1) when Resident 1 ' s foley catheter care was not provided every shift. This failure has the potential for an increased risk of recurrence of infection for Resident 1.

Inspectors wroteBased interview and record review the facility failed to administer three routine medications (Quetiapine Fumarate, Mirtazapine, and Lactulose) on August 9, 2023, in accordance with the policy and procedure for one of four sampled residents. This failure had the potential to result in harm to Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure undated/unlabeled and expired food items were not stored in the refrigerator, readily available for use. This failure had the potential to result in foodborne illness to an already vulnerable facility population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory services according to professional standards of practice when: 1. The licensed nurses administered oxygen without the oxygen flow rate specified in the physician's orders for 14 shifts, from June 3, 2022, to June 8, 2022, for one of four residents reviewed for oxygen use (Resident 212). This failure had the potential for Resident 212 to receive ineffective or unnecessary oxygen therapy. 2. The facility did not change the oxygen nasal cannula (NC - a tube used to deliver oxygen through the nose) and oxygen set-up bag, for two of four residents reviewed for oxygen use (Residents 1 and 50). This failure had the potential for bacterial growth in the NC, which could cause respiratory infections in Residents 1 and 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the professional principles on storing medications when: 1. One bottle of antifungal powder, dated May 11, 2022, was found on Resident 49's nightstand and there was no physician's order for use. This failure had the potential for Resident 49 to receive antifungal powder unnecessarily. 2a. One tube of Santyl ointment (medication that removes dead tissue from wounds so they can start to heal) labeled for a discharged resident was found stored in the treatment cart readily available for use; and 2b. One bottle of Narcan (medication used for the treatment of a known or suspected use of opioid [medication used mostly to relieve pain] overdose) nasal spray labeled for a discharged resident was found stored in the medication cart readily available for use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention and control was practiced when: 1. One dirty bedpan was found on the floor in Resident 49's room; and 2. Resident 49's CPAP (Continuous Positive Airway Pressure - a common treatment for obstructive sleep apnea [breathing stops temporarily]) machine was not cleaned since his admission on [DATE]. These failures had the potential to increase the risk of bacterial growth, cross-contamination, and infections.