South Bay Post Acute Care

Inspectors wroteBased on interview and record review, the facility failed to ensure physician (MD) ordered wound care treatments for pressure ulcer ((localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) were implemented as directed for one of three sampled residents (Resident 1). As a result, Resident 1's pressure ulcer on the sacrum (the base of the spine or simply the bottom of the back) increased in size and placed Resident 1 at risk for worsening skin integrity, potential infection, delayed healing, and further complications related to pressure ulcer progression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide clear indications (a valid reason to use a certain medication) for two of three sampled residents ' (Resident 1 and Resident 2) controlled pain medications (medications with high abuse potential). As a result of this deficient practice, Resident 1 and Resident 2 were at risk of receiving unnecessary controlled pain medications which may lead to misuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document a pain assessment result and controlled pain medication (medications with high abuse potential) administration in the Medication Administration Record (MAR) for one of three sampled residents (Resident 1). As a result of this deficient practice, Resident 1 ' s MAR did not accurately reflect the care and treatment provided to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident ' s (Resident 2) controlled medications were secured and disposed of after discharge to the hospital. This deficient practice had the potential to result in drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff promptly answered resident call lights and met resident's needs in a timely manner for two residents interviewed on the initial tour of the facility and three of seven residents from the confidential group interview. This failure could potentially affect these residents' physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure all staff were trained regarding behavioral health. Only 17 licensed nurses were in-serviced according to the in-service sign-in sheet. As a result, there was a potential for staff to not have the knowledge to care for residents with behavioral health issues.

Inspectors wroteBased on interview and record review, the facility did not assure staff assisted Resident 66 in timely manner to maintain continence (ability to control movements of the bowels and bladder). As a result, Resident 66 became incontinent (lost control of bowel or bladder) and felt as if she had been ignored and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a self-administration assessment was accurate for one of one resident (Resident 33) reviewed for self-administration of medication. This failure increased the potential for the unsafe self-administration of medications, and the duplication of administered medications for Resident 33.

Inspectors wrote2. Resident 33 was admitted to the facility on [DATE] with diagnoses to include Congestive Heart Failure (CHF - a serious condition in which the heart doesn't pump blood as efficiently as it should), per History & Physical, dated 2/10/22. During observation and interview on 11/14/22, at 12:27 p.m., Resident 33 was in her room having lunch. Resident 33 stated she had no teeth but had dentures that were lost 3 months ago. Resident 33 stated she informed the head nurse and was told they will look for them. On 11/17/22, at 10:27 a.m., CNA 4 was interviewed. CNA 4 stated Resident 33 had dentures but refused to wear them. CNA 4 stated Resident 33 had no problems chewing. CNA 4 stated if a resident had missing dentures, she would report it to social services. CNA 4 stated she had not seen Resident 33 wear her dentures in the last 2 weeks. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review Level II (PASRR II - an evaluation of the resident's psychiatric treatment requirements) was followed up and completed for one of one resident (Resident 17) reviewed for PASRR. As a result, there was potential for a failure to coordinate the PASRR recommendations to Resident 17's assessment and care planning.

Inspectors wroteBased on observation, interview and record review, the facility failed to update or revise care plans for two of three residents reviewed for care planning (8, 78). This failure had the potential to result in delayed care, miscommunication among caregivers, and decreased physical well-being of the residents.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan for discharge for one of four residents reviewed for care planning (Resident 49). This failure had the potential to result in an unsafe discharge, and placed Resident 40 at risk for prolonged admission to the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed provide treatment and care according to professional standards of practice when: 1. The need for a PRN (provided as needed) medication was not assessed for one of one residents reviewed for constipation (Resident 36), and 2. A physician's order to assist a resident up in a chair daily was not followed for one of three residents reviewed for care planning (Resident 49). 3. Blood sugar level checks were not performed before meal intakes for one of 3 residents reviewed for diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired) care. These failures had the potential to place the residents at risk for further medical complications.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a toilet seat was securely attached to the toilet bowl in a communal bathroom used by multiple residents. As a result, multiple residents were at risk for falls due to the instability of the loose toilet seat.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one of one residents (31) on intravenous (IV) antibiotic therapy had their PICC line monitored per professional standards and facility policy. A PICC line is a peripherally inserted central catheter that provides access to the large vein carrying blood to the heart to administer medication for long-term use. This failure could potentially increase the risk of infection and delay the identification of catheter-related complications for Resident 31.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician's order for oxygen therapy was followed for one of one resident (Resident 33) reviewed for respiratory care. As a result, Resident 33 was provided with more oxygen than what the physician ordered, which had the potential to cause respiratory problems for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of four residents reviewed for dialysis (a process to remove waste products from the blood) had a dressing removed as ordered by the physician (Resident 36). This failure had the potential to cause damage or injury to the dialysis site.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure behaviors related to the use of an antipsychotic was accurately monitored for one of 5 residents (Resident 33) reviewed for unnecessary use of psychotropic medications. As a result, Resident 33's documented behavior showed an increase in behavioral episodes which could potentially result in inappropriate dosing of the antipsychotic medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure care conference documentation was accurate for one of 20 resident (Resident 33) reviewed for accurate medical record. This failure did not provide an accurate representation of the care provided to Resident 33 and had the potential to cause confusion amongst care providers.

Inspectors wrote2. During observation and interview on 11/14/22, at 2:52 p.m., CNA 3 was observed coming out of room [ROOM NUMBER] and carried a urinal filled with urine, while both hands were gloved. CNA 3 held the urinal with his right hand and closed the door to room [ROOM NUMBER] with his left hand. CNA 3 proceeded to enter the hall restroom and came out holding the urinal with his left hand. CNA 3 turned the doorknob with his right hand to enter room [ROOM NUMBER]. An interview was conducted with the Infection Preventionist (IP) on 11/21/22, at 3:34 p.m. The IP stated staff used the restroom across the hall for room [ROOM NUMBER]. The IP stated he trained staff not to use gloves in the hallway. The IP stated he trained staff to use a barrier on holding a urinal. [...]

Inspectors wroteBased on interview and record review the facility did not clarify one of two residents' (287) wishes for life sustaining treatment. This failure created the potential for Resident 287 to receive life sustaining treatment not according to his wishes.

Inspectors wroteBased on observation, interview, and record review, one of four residents (28) received treatment for a pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) without a physician's order. This created the potential for Resident 28 to receive unsafe care.

Inspectors wroteBased on interview and record review, the facility failed to provide showers and hair washing for one of two sampled residents (187). This failure had the potential for the resident to experience psychological stress and compromised hygiene.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and manage pain for two of four residents investigated for pain management (24, 20). As a result, the deficient practice had the potential for unmanaged pain.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure dialysis (the process of cleaning the blood through a machine) care was given according to professional standards of practice for two of five residents (287, 186). This practice created the potential for: 1. Resident 287's temporary access site (central line located in the right upper chest) and AV fistula (artery and a vein surgical connection created for dialysis treatment) to become infected and for the AV fistula to clot. 2. Resident 186's access site to clot.

Inspectors wroteBased on observation, interview and record review, the facility failed to individualize behavioral interventions for one of three residents (43). This failure had the potential to result in Resident 43's safety being compromised.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of five residents (20) reviewed, received anti-anxiety medications for an approved indication and behaviors. As a result, Resident 20's distress was not accurately assessed or treated.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor dietary preferences for one of four residents (78), which resulted in Resident 78 receiving foods she disliked.

Inspectors wroteBased on observation, interview, and record review, one of one resident (28) was not provided adaptive equipment for meals. This failure created the potential for Resident 28 to limit her intake at mealtimes.

Inspectors wroteBased on observation, interview, and record review, the facility did not implement infection control related to hand hygiene. This practice created the potential for transmission of HAI (healthcare associated infections) to residents, staff, and visitors.