Serenethos Care Center, LLC

Inspectors wroteBased on interviews and record review, the facility failed to ensure that when it hired a part-time registered dietitian, the person designated to serve as the director of food and nutrition services met both the federal and/or state educational qualifications for the position. This failure had the potential for lack of competency and skill set necessary to carry out all the functions of the food services.

Inspectors wroteBased on interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) assessment for one of one sampled residents (Resident 1) was completed and coded accurately. This failure to accurately code Resident 1's PASRR assessments placed Resident 1 at risk to not receive care and services appropriate to his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5% for one out of four sampled residents (Resident 23) when nursing staff administered 4% lidocaine patch to Resident 23's knees on two separate days, instead of to the back as prescribed by the physician. These failures resulted in two medication errors being identified out of 27 opportunities during an observation of medication administration leading to a medication error rate of 7.41%. These deficient practices had the potential to result Resident 23 not having pain relief.

Inspectors wroteBased on the observations and interviews conducted, it was concluded that the facility failed to provide pharmaceutical services to meet the needs of each resident. This conclusion was drawn due to the discovery of expired medications found in the medication storage areas. Expired medications can no longer be considered viable or safe to administer, and thus will not meet the needs of the residents who require effective and safe pharmaceutical care.

Inspectors wroteBased on observations, interviews, and a review of records, it was found that the facility failed to maintain a medication error rate of less than 5%. During the medication pass, eight medication errors were observed out of twenty five opportunities for five of six residents, resulting in an error rate of 32%.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored and prepared in a safe and sanitary manner when: 1. A trash can in the dishwashing area was left uncovered. 2. The microwave was not clean. 3. Two packs of unopened corn Tortilla and one pack of opened Tortilla with a few left in the plastic bag, had expired. 4. A half full bag of premium golden light brown sugar with no received date and still in its paper sack. 5. A half full bag of salt still in its paper sack. These failures had the potential to result in contamination of food causing food borne illness for 30 residents who received food from the kitchen out of a facility census of 31.

Inspectors wroteBased on observation, interview, and document reviews it was found that the facilities' Quality Assessment Performance Improvement (QAPI) program was ineffective. Despite its purpose to proactively identify and prevent medication administration errors, it fell short. This was evident during a medication pass observation conducted during the survey, which revealed a concerning 32% medication error rate (See F759).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff followed the infection prevention and control policy and procedure (P&P) to prevent spread of infection for two of four sampled residents (Resident 30 and Resident 8) when: 1) The nebulization mask (a medical device used to deliver medication in the form of mist, which is inhaled into the lungs) of Resident 30 was not dated or labelled and left exposed in the bedside table drawer touching other personal items and the drawer surface with brownish dusty material. 2)The nebulization mask and CPAP mask (continuous positive airway pressure machine is used in the treatment of sleep apnea. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the dish machine in safe operating condition when the temperature did not reach 120° (degrees) Fahrenheit (F). This failure had the potential for food preparation and food service utensils placed in the dish machine to not become fully cleaned and sanitized before being used.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 80 square foot of space per resident for 8 residents who occupied 4 multi-bed bedrooms. This condition had the potential to result in lack of sufficient space for the provision of care both routine and emergency and for residents to have their personal belongings at bedside.

Inspectors wroteBased on observation and interview, the facility failed to ensure an effective pest control program when flies were observed in the kitchen. This failure had the potential to cause food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a working wall clock for one of one sampled resident (Resident 19) in her room. This failure placed Resident 19 at risk for confusion and disorientation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of four (4) sampled residents (Resident 20 and Resident 18) received proper grooming including nailcare when: 1. Resident 20 had long fingernails with black matter underneath 2. Resident 18 with contractures had long sharp nails digging into palms. This failure placed residents at risk for getting infections from lack of proper hygiene and injuring themselves with long fingernails and compromised physical and psychosocial wellbeing.

Inspectors wroteBased on interview and record review the facility failed to act upon consultant pharmacist's recommendations for clarification of indication of use for trihexyphenidyl (a medicine that improves muscle control and reduces stiffness in Parkinson's disease and other conditions) for one of five sampled residents (Resident 12). This deficient practice resulted in Resident 12 receiving unnecessary medication without proper indication and had the potential to negatively impact the resident's well-being.

Inspectors wroteBased on observation, review of facility documents, and staff interviews, the facility failed to comply with federal regulations related to the oversight of food service operations when the facility did not have a full-time dietitian and the requirements were not met as specified in established standards (California Code, Health and Safety Code - HSC § 1265.4) for food service managers which required, employment of a full-time dietetic supervisor when the dietitian was not full time. Multiple issues were observed including the Food and Nutrition Services Department did not have a system in place to ensure the appropriate texture of food was prepared and served; the Food and Nutrition Supervisory staff did not ensure food safety and sanitation; [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure nursing staff demonstrated appropriate competencies and skillsets necessary to care for residents' needs when physician prescribed food texture was not verified before serving food to residents, and when Certified Nursing Aide 3 (CNA 3) did not have the knowledge to identify the appropriate food texture in accordance with the diet order before serving food to a resident. These failures had the potential for one resident (Resident 34) out of a facility census of 35, to aspirate (to breath in or inhale foreign objects into the lungs. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a resident (Resident 34) a special dietary need as well as ensure Food and Nutrition Services had a system in place for preparing and serving the correct diet texture according to the physician's order when a regular texture diet (a diet that includes all textures of food including hard, tough, chewy, fibrous, stringy, dry, crispy, and crunchy; and intended for people without chewing and swallowing issues) was prepared for a resident (Resident 34) with prescribed modified texture Full Liquid diet (a diet made with fluids and foods that are normally liquid and/or turn to liquid when they are at room temperature). [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of staff when: 1. Staff did not know how to test the food-contact surface sanitizer; 2. Staff were not able to calibrate thermometers used to measure the temperature of food; 3. Staff did not know appropriate procedures for manual dishwashing; 4. Staff did not follow a recipe for the planned menu; and 5. Staff did not know the appropriate water temperature required for the dish machine. The failure to ensure staff had the competency to properly complete necessary tasks had the potential to result in food borne illness, as well as health complications for not receiving the nutrients intended by the planned menu, for 29 residents who received food from the kitchen out of a facility census of 35.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary manner when: 1. Meat was not thawed or stored properly; 2. Staff did not wash hands, use gloves, and use the handwashing sink properly; 3. Refrigerated food was not stored at an appropriate temperature; 4. Refrigerated food was moldy and not discarded by the use-by-date; 5. Equipment and utensils were found stored dirty and in poor condition; and 6. Storage cabinets, and drawers used for storing food and cooking utensils were not clean and in poor condition These failures had the potential to result in contamination of food and food borne illness for 29 residents who received food from the kitchen out of a facility census of 35.

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage dumpster bins located outside, had lids that tightly closed. This failure had the potential to attract pests to the facility and lead to pest related disease for 35 residents out of a facility census of 35.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow policies and procedures for infection control for 35 of 35 facility residents when: 1. Staff did not wear face masks appropriately and, 2. Facility did not have policy or procedure to monitor water for waterborne pathogens (disease causing micro-organisms which can grow in water). These failures had the potential result in respiratory or waterborne infection for facility residents.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to: 1. maintain the dish machine in safe operating condition when the temperature did not reach 120 degrees Fahrenheit (F) . 2. ensure a food preparation sink drain had an airgap ((a gap of air created so a food equipment drainpipe is not directly connected to a drain containing sewage or wastewater). This failure to maintain the dish machine water temperature had the potential for food preparation and food service utensils placed in the dish machine to not become fully cleaned and then used; in addition, the failure to maintain an air-gap in the food preparation sink drain had the potential for the sink to become contaminated from waste water and then result in contamination of food, for 29 residents who received food from the kitchen out of a facility census of 35.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 24) received fingernail trimming as needed. The failure to trim Resident 24's fingernails resulted in discomfort from the nails digging into the palms of both hands, which had contractures ((a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints and decreased mobility and function). This failure also had the potential to result in scratches, wounds, and infections from the long nails.

Inspectors wroteBased on observation, interview, and record review for one of four sampled residents (Resident 24), the facility failed to continuously assess the urine in the indwelling catheter tubing (a tube secured inside the bladder to drain urine into a bag outside the body). This failure could potentially result in delayed resolution of a possible urinary tract infection (UTI, an infection in any part of the urinary tract - kidneys, bladder, or urethra).

Inspectors wroteBased on observation and interview, the facility had four resident rooms (1, 5, 6, 12) with multiple beds that provided less than 80 square feet (sq.ft) per resident who occupied these rooms. This deficient practice had the potential to result in inadequate space for the delivery of care to each of the residents in each room, or for storage of the residents' belongings.