Saratoga Retirement Community Health Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nurse staffing information was posted clearly visible in a prominent place that was readily accessible to residents and visitors. This failure had the potential to result in nurse staffing misinformation about resident's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food handling techniques in the kitchen when several wet metal containers were stacked while still wet and dry storage room walk-in refrigerator, and freezer had expired and unlabeled food. There se failures had the potential to expose 62 residents receiving food from the kitchen to food-borne illness.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure physician's orders were followed related to supplemental oxygen administration for 1 (Resident #12) of 1 sampled resident reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu was followed for seven residents on Pureed diet (texture modified diet for people who have difficulty chewing and swallowing) and nine residents on Mechanical soft diet (texture modified diet for people who have difficulty chewing and swallowing). This failure had the potential to result in not meeting the nutritional needs of the residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to follow proper sanitation and food handling practices when: 1. There were food remains on a food container in dry storage area; 2. There was an outdated food item in dry storage area; and 3. Steam table pans were stacked and stored wet. These failures had the potential to cause food contamination and food-borne illness to 63 of 64 residents who received their food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respect and dignity was maintained for two residents (Residents 12 and 42) when staff provided feeding assistance while standing. This failure had the potential to affect the emotional and psychosocial well-being of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of four sampled residents (Resident 39). This failure had a potential to endanger the health or safety of the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and service in accordance with professional standards of practice for four of 16 sampled residents (Resident 33, 28, 21 and 9) when: 1. Resident 33's dermasaver to legs and wound dressing on left second toe were not administered as ordered; 2. staff did not document behavior observation and medication side effects monitoring on time for Resident 28, 21, and 9. These failures had the potential to affect the residents' care and jeopardize their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of accidents and hazards for two of 16 sampled residents (Resident 42 and 1) when: 1. Resident 42 was not provided adequate supervision as indicated in her fall care plan and fall mats were not in place as ordered; 2. Resident 1's wandering alert system was not monitored. These failures had the potential to result in serious injury to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and dispose of multiple expired and unlabeled medications properly in one of two medication rooms, and one of two medication carts. These failures had the potential to result in unsafe administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when staff did not wash or sanitize her hands between changing gloves for one of four sampled residents (Resident 36). This failure could potentially result in infection transmission in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure food was stored and prepared under sanitary conditions when kitchen staff used expired test strips to test the kitchen surface sanitizer and scooped ice from ice machine not using ice scooper. These failures had the potential to spread food-borne illness to 69 of 72 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy on medication self-administration (resident takes medication without staff assistance) for one of 18 residents (Resident 48) when: 1. The facility did not complete a medication self-administration assessment for Resident 48; 2. The facility did not obtain a physician's order for Resident 48 to self-administer medications; and 3. The facility did not ensure Resident 48's medication was kept in a locked container in his room. These failures had the potential to result in unsafe medication self-administration.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify and address potential complications related to indwelling catheter (flexible tube inserted and left in the bladder to drain urine) use for one of four residents (Resident 17). This failure had the potential to negatively affect the resident's health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the necessary care and treatment was provided for one of one sampled resident (Resident 64) in accordance with professional standards when the registered nurse (RN) failed to use the proper technique of flushing the peripherally inserted central catheter (PICC, a long, slender, flexible tube inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart to obtain intravenous access) line. The dynamic of the injection flow plays a pivotal role in adequate and correct flushing. Flushing using a so-called push-pause, pulsatile, or turbulent technique enhanced the rinsing effect in the catheter and helps prevent catheter occlusion.

Inspectors wroteBased on interview and record review, the facility failed to consistently complete post dialysis (the clinical purification of blood as a substitute for the normal function of the kidney) assessments on the Nursing Facility/Dialysis Center Communication Report for one resident (Resident 17) who received dialysis services. Failure to assess had the potential to compromise the facility's ability to identify and address potential complications after dialysis.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure controlled medications had been accurately accounted for one of four Controlled Drug Medication Carts, that were checked, when the licensed nurse did not timely document/log the morphine sulfate (MSO4- opioid pain medication) that was dispensed and administered to Resident 25. This failure had the potential to create problems related to accounting of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to provide a monthly review of antipsychotics (drugs used to treat mental health disorders) and psychotropics (drugs that affect behavior, mood, thoughts or perception) by a licensed pharmacist for one of five residents (Resident 3) reviewed for unnecessary medications, which had the potential to result in the physician not acting upon the medication irregularities.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five residents reviewed was free from unnecessary psychotropics, when: (1) There was no adequate indication for Resident 3's use of Geodon, Neudexta, Wellbutrin and Paxil, and (2) There was no GDR (gradual dose reduction) attempts in two separate quarter within the first year for Geodon, Wellbutrin and Paxil. These failures had the potential to cause medication adverse effects.

Inspectors wroteBased on observation, interview, and record review, the facility had a 6.45 percent error rate when two medication errors out of thirty-one opportunities were observed during a medication pass. These failures resulted in the medications not being administered according to the physician's orders and manufacturer's specifications.