Sunnyvale Gardens Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure treatment and care provided were in accordance with professional standards of practice for one (Resident 1) out of two residents, when Resident 1 did not receive a medication ordered by the physician. This failure resulted in multiple missed doses of Resident 1's medication that had the potential to worsen Resident 1's physiological being.

Inspectors wroteBased on observation, interview and record review, the facility failed 1) To implement and inform all residents of their Smoking Policy upon admission. Census during the survey on 11/21/24 was 127. 2) To ensure a safe environment free from accidents when one (Resident 1) out of six sampled residents suffered burns from an electronic cigarette (e-cigarette, a cigarette-shaped battery-operated device that contains nicotine, flavorings, and other chemicals that create an aerosol that is inhaled into the lungs, used to simulate the experience of smoking tobacco) explosion. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff competently carried out the functions of the food and nutrition services department according to facility policy and standards of practice when: 1. One dietary support staff did not know how to properly test the sanitizer in the red bucket (bucket containing sanitizer solution used for sanitizing food contact surfaces), and 2. Two dietary support staff members did not correctly demonstrate how to calibrate a thermometer used to test food temperatures These failures had the potential to expose residents to bacterial contamination, which could result in food borne illnesses for all residents who consumed food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain dignity and privacy to five of five residents (Residents 29, 11, 100, 76 and 64) when: 1. Residents 29, 11, 100, and 76's personal information and care guide were posted in their rooms visible to their roommate's visitors; and, 2. Registered nurse L (RN L) did not close the privacy curtain and door during medication administration thru gastric tube (GT - a surgical opening into the stomach for administration of nutrition, and medications). These failures had the potential to negatively affect resident's emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall management and safety supervision policy and procedures were implemented for nine out of 10 residents (Residents 18, 76, 106, 26, 30, 90, 108, 116, and 122) when: 1. Staff did not provide 1:1 supervision (one to one continuous observation - terms used for a registered nurse or health care support worker whose role is to provide one to one nursing or observation care to an individual patient for a period of time to help prevent a fall or redirect a patient from engaging in a harmful act) as ordered and/or careplanned for Residents 18, 76 and 106 who were identified as high risk of falling; and 2. Staff did not provide 1:1 supervision, and there were no monitoring logs for Residents 26, 30, 90, 108, 116, and 122 who were identified as at high risk of falling. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate accountability of controlled drugs (medications that can be easily abused and are under strict government control) and document medication administration as in accordance with the facility policy and procedures (P&P) for one out of six sampled residents (Resident 2). The failure had the potential for medication errors and controlled drug abuse or diversion (when healthcare providers obtain or use prescription medicines illegally).

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 10% when three medication errors occurred out of 30 opportunities during the medication administration for three out of seven residents (Resident 8, Resident 64, and Resident 51). The failures resulted in the nursing staff not following physician's orders and the facility's policy and procedures (P&P), which had the potential for the residents not receiving full therapeutic effects, or complications from medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when opened multi-dose vials/inhalers had no open date; unopened latanoprost (used to treat glaucoma [group of eye diseases that can cause vision loss and blindness]) bottles were not stored in the refrigerator as per manufacturer's labeling; and, expired medications were not removed from active stock. These failures had the potential for residents to receive medications with reduced efficacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were implemented when: 1. Certified nursing assistants did not perform hand hygiene in between residents' lunch tray set up; 2. Residents 8 and 107's oxygen concentrator's (a device which concentrates the oxygen from ambient air) filters were not changed and had some grayish substance build-up; 3. Residents 51, 59 and 18's nebulizer (a small machine that turns liquid medicine into a mist that can be inhaled directly into the lungs) mask and tubing were not properly stored when not in used; 4. Wound nurse (WN) did not change gloves in between wound treatment; 5. Staff did not perform proper hand hygiene during Resident 26's care; 6. Resident 45's oxygen humidifier was not changed in a timely manner and the gastric feeding tube port was on the floor uncovered; 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure on self-administration of medication (resident takes medication without staff assistance) when there were no assessments performed for self-administration of medication, and medications were left at bedside for one of six sampled residents (Resident 59). This failure had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement comprehensive care plans that included target symptoms, measurable objectives, and interventions for three out of 26 sampled residents (Resident 6, Resident 106, and Resident 111) as follows: 1. For Resident 6, the facility did not develop care plans for depression (loss of pleasure or interest in activities for long periods of time) and anxiety (apprehensive uneasiness or nervousness usually over an impending or anticipated). 2. For Resident 106, the facility did not develop care plans for depression and Parkinson's disease (a disease that include symptoms of slowness of movements, muscle rigidity, involuntary tremors/shaking and impaired balance, and posture). 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided were in accordance to standards of practice when staff did not use the correct denture cleanser for one out of eight sampled residents(Resident 26). This failure had the potential to affect the integrity of Resident 26's dentures and may not be effective to remove stains and kill bacteria.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their policy and procedures for enteral feeding (a method of delivering nutrients and fluids directly to the gastrointestinal [GI] tract) care for two of two sampled residents (Residents 110 and 64) when: 1. Licensed vocational nurse G (LVN G) did not check the placement (by injecting air and listening to the stomach with a stethoscope) of a gastrostomy tube (G-tube, a tube that goes directly into the stomach to deliver feeding formula and medications), and did not check for any residual (the amount of fluid remaining in the stomach after enteral feeding, which is measured by withdrawing the fluid with a syringe and checking the amount) prior to flushing the G-tube with water; and, 2. Registered nurse L (RN L) did not check G-tube placement before G-tube medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy regarding use of side rails (also called bedrails, metal or plastic bars attached to the bed ranging in size from full to one-half, one quarter, or one-eighth lengths) for one out of 26 sampled residents (Resident 22), when Resident 22 did not have a documented physician's order for the use of side rails, there was no documentation that indicated the facility attempted alternatives prior to installing the side rail, and there was no documentation that indicated the facility assessed for risk of entrapment (getting caught, trapped, or entangled in the space in or around the side rail). These failures had the potential to compromise the resident's safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff had the necessary competency to respond to resident's needs when two (Resident 90 and Resident 122) out of four residents were assisted by the laundry aide. This failure had the potential for the facility to not meet residents' safety needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate social services (SS) support for one of three residents (Resident 59) when there was a lack of SS support for Resident 59, who had a history of domestic violence (also called intimate partner violence, a pattern of behavior in any relationship that is used to gain or maintain power and control over an intimate partner). This failure resulted in a lack of timely psychosocial support for Resident 59.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 26 sampled residents (Residents 6 and 111) were free from unnecessary medications when Resident 6 received Lasix (used to treat edema [fluid retention; excess fluid held in body tissues]) and Resident 111 had two orders for oxycodone (a potent controlled medication for pain) 5 milligram (mg, unit of measure). This deficient practice resulted in unmonitored medical condition; and, duplicate orders that had the potential for excessive dose/adverse effects for the resident.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure three out of 26 sampled residents (Residents 59, 6, and 63) were free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Resident 59 received an anti-anxiety (a type of medication used to prevent or relieve anxiety) and two different antidepressants (type of medication used to treat depression) without documentation wherein non-pharmacological interventions were attempted prior to psychotropic medication used; 2. Resident 63 received Abilify (is an antipsychotic [drugs treat psychosis] medication that helps treat several kinds of mental health conditions) without target behavior monitoring, and there was no documentation of non-pharmacological interventions implemented; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure implementation of their Antibiotic (medication infection) Surveillance (timely collection, analysis, and communication of data) protocol when antibiotic use for two (Resident 111 and Resident 331) out of three sampled residents whey they were not monitored and tracked. This failure had the potential to place residents at risk for a development of antibiotic resistance (when bacteria change to resist antibiotics that once effectively treated them).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were properly functioning and accessible for four sampled residents (Resident 97, 104, 122, and 232) when: 1. Resident 232 's call light was not in reach while in bed; 2. Resident 97 and Resident 104's call lights were not functioning; and, 3. Resident 122's call light was not within reach while in bed. These failures could prevent residents from communicating with staff for basic needs and in emergency situations, which could potentially compromise the resident's care and safety.

Inspectors wroteBased on interview and record review the facility failed to provide required supervision and assistance and failed to implement a resident's minimum data set (MDS: clinical and functional assessment tool) assessment for assistance for bed mobility, transfers, toileting, ambulation, and risk for falls care plan for transfer and ambulation assistance, to prevent a fall on 2/3/2024 for one of 2 sampled residents (Resident 1). These failures resulted in Resident 1's fall and subsequent transfer to acute hospital (AH: where residents receive short term treatment for an urgent medical condition or severe illness) where Resident 1 was diagnosed with left wrist fracture (broken wrist bones).

Inspectors wroteBased on interview, and record review, the facility failed to follow their policy and procedure (P&P) to safely secure and return personal belongings to one of one sampled resident (Resident 1) after Resident 1 was transferred to acute hospital (AH: where residents receive short term treatment for an urgent medical condition or severe illness). This failure had the potential for losing Resident 1's personal belongings, and negatively affect Resident 1's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their abuse policy and procedure for one of one resident (Resident 2) when the facility did not report Resident 2's injury of unknown source. This failure resulted in Resident 2's fractures of left third and fourth metacarpals (broken middle and ring fingers) of unknown source not reported to required agencies (California Department of Public Health [CDPH], law enforcement agency, and Long-Term Care Ombudsman). This failure had the potential to compromise the safety of the residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to maintain accurate and systematically organized documentation in accordance with accepted professional standards and practices for three of three sampled residents (Resident 1, 2, and 3) when: a. Nursing documentation for Resident 1's allegation of abuse was not documented; b. Nursing documentation for Resident 2's allegation of abuse was not documented; c. There were no care plans for Residents 1, 2, and 3 for abuse allegations. These failures resulted to an inaccurate documentation of the care provided for Residents 1, 2, and 3

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication for two out of three medication storage rooms and three out of five medication carts, when: 1. Seven insulin (medication to treat high blood sugar) pens (devise to use to give preloaded insulin) had the pharmacy label on the caps instead of the body of the pens. 2. Two opened bottles of lorazepam ( medication used to treat anxiety disorder) were found in the medication refrigerator with no open date . 3. One inhaler (handheld portable device that delivered medication into the lungs) was found in the medication cart without open date. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat residents with respect and dignity, and care for each resident in a manner and in an environment that promoted their rights that enhanced their quality of life for four of of 23 sampled residents (Resident 36, 39,102, and 162) when 1. For Resident 102, the primary care physician (PCP, her attending physician) called her as, too heavy to reach your goal, the interdisciplinary team (IDT, facility staff members from different departments who coordinate care provided to residents) did not invite her to participate during the care planning conference, and she was categorized as incontinent (having no or insufficient voluntary control over urination or defecation) which resulted to her feeling insulted and angry; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for six of 23 sampled residents (Residents 94, 28, 107, 11, 36, 43, ) when: 1. For Resident 94, a physician order for oxygen (O2, a colorless and odorless gas that people need to breathe ) was not followed and signage was not provided; 2. For Resident 28, license nurse did not follow the physician's order to administer O2 continuously at 2LPM (two liters per minute) via NC (nasal cannula); 3. For Resident 107, license nurse did not ensure the physician's order to increase the O2 to 4LPM via NC during therapy, and did not carry out the physician's order regarding the laboratory orders; 4. For Resident 11, the physician's order for oxygen was not followed; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of accidents for four of 23 sampled residents (Residents 15, 45, 74, and 410) when: 1. Resident 15 was transferred using a Hoyer lift (equipment used to transfer residents using a sling) with only one staff; 2. Staff did not keep Resident 45 's smoking materials, and oxgen signage was not posted; 3. Staff did not provide adequate supervision to prevent Resident 74 going out of facility unattended; 4. Licensed nurses did not monitor Resident 410 post fall, inform the physician about the fall , and update the fall care plan . 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 ensure 12 of 23 sampled residents (Resident 102, 162, 10, 82, 2, 3, 7, 11, 36, 52, 22 and Resident 45) were free from unnecessary psychotropic (any drug that affects brain activities associated with mental processes and behavior) medications when the psychotropic medications ordered did not include monitoring of the targeted behaviors every shift, and the monitoring of side effects were not specific to each type/classification of psychotropic medications. These failures had the potential to result in staff not monitoring the intended target behaviors, the side effects of the medication and not properly evaluating the effectiveness of the psychotropic medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored in accordance with professional standards for food safety when 1. Undated food, food past their best-by or use-by date, and expired food were found in the refrigerator and on the shelves in the kitchen; and 2. The ice machines did not have air gap. These failures had the potential to cause the growth of micro-organisms which could cause foodborne illness and cross-contaminated food for the 109 residents eating at the facility.

Inspectors wrote2. Review of Resident 2's physician order indicated he had an order for oxygen 4 liters (L, a metric unit of volume) per minute every shift for short of breath, started on 1/10/22. Resident 2 also had an order for ipratropium-albuterol solution (used to relax and open the air passages to the lungs to make breathing easier) 0.5-2.5 (3) milligrams (mg, a metric unit of mass) per 3 milliliters (ml, a metric unit of volume) inhale orally four times a day for short of breath, started on 1/12/22. During an observation with licensed vocational nurse N (LVN N) on 11/14/22 at 1:09 p.m., Resident 2 was on oxygen. The oxygen tubing was undated, and the filter of the oxygen concentrator was dusty. Resident 2's nebulizer (a device that turns the liquid medicine into a mist so it can be inhaled into the lungs) mask and tubing were also undated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents' needs were accommodated for three sampled residents (Residents 31, 9, and 40 ) and one non-sampled resident (Resident 60) when: 1. Bedside call light or equipment was not placed within reach for Resident 31, 9 and 40, which could potentially result to resident's inability to access assistance to meet his needs. 2. Call light was not answered in a timely manner for Resident 60, which had the potential to result in the delay of responding to residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual was incapacitated) accurately reflect on the Physician Order for Life-Sustaining Treatment (POLST, a document signed by the resident and by the physician which indicated the types of medical treatment the resident wished to receive towards the end of life) and the physician order for one sampled resident ( Resident 27). This failure had the potential for the facility to provide treatment and services that was against the resident's wishes.

Inspectors wroteBased on interview and record review, the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN, a notice that transfers potential financial liability) to two of three residents (Resident 89 and 92) in timely manner. This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the facility's decision to discontinue Medicare Part A services (skilled treatments paid for by Medicare). This failure also had the potential to result in the residents or residents' representatives not being informed of their payment responsibilities to the facility after Medicare Part A services ended.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop, implement and/or update the care plans for five of 23 sampled residents (Residents 28, 107, 164, 31, and 84) when: 1. For Resident 28, there was no care plan developed for urinary retention, and licensed nurse did not follow the doctor's order to notify the doctor when the bladder scan result was greater than 300 ml. (milliliter, unit of measurement). 2. For Resident 107, there was no care plan developed for limitation in the range of motion (ROM), and urinary incontinence to help prevent pressure ulcer (PU, an injury that breaks down the skin and underlying tissue caused when an area of skin is placed under pressure); and did not implement care plan for left ram swelling and left foot edema. 3. For Resident 31, the care plan did not reflect the correct diagnosis on admission. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the individualized and comprehensive care plans to meet individual needs for three residents (Residents 27, 45, and 96 ) when : 1. For Resident 27, an oxygen (O2, a colorless and odorless gas that people need to breathe) care plan was not discontinued when no longer in use. 2. For Resident 45, the port (a device used to draw blood and give treatments, including intravenous fluids, blood transfusions, or drugs. The port is placed under the skin, usually in the right side of the chest) site care plan was not updated to include a new diagnosis after a hospitalization, and; 3. For Resident 96, the discharge care plan was not updated when her discharge plan was changed. These failures had the potential to result in not meeting the residents' needs.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards when nurse practitioner (NP) added a diagnosis of Schizophrenia or bipolar disorder for the antipyschotic medication use not previously included as one of the resident's diagnoses for one of two residents (Resident 82). This failure could potentially compromise Resident 82's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for one sampled resident (Resident 31). This failure placed the resident at risk for infection and self-inflicted skin injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate treatment was rendered for one sampled resident (Resident 84) to prevent complications of enteral (refers to the delivery of a nutritionally complete feed, containing protein, carbohydrate, fat, water, minerals, and vitamins, directly into the stomach, duodenum or jejunum) feeding. This failure could result in health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of practice for one sampled resident (Resident 45) with a central venous line (a catheter placed into large vein commonly placed in veins of neck, chest, groin, or through veins in the arms to administer medications or prolonged intravenous therapies such as parenteral nutrition ) and receiving parenteral nutrition (TPN, to infuse specialized form of food through an IV) when the central venous dressing was not done properly, there was no flushing order, the physician order did not indicate the correct site , care plan was not revise to reflect the correct site and implement intervention, and intake and output was not initiated .These failures had the potential to affect the residents' health conditions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident receiving dialysis (removal of waste and excess fluid from the body) treatment received care consistent with professional standards for one sampled resident (Resident 85) when his Hemodialysis Communication Forms (HCF) were incomplete and missing. This deficient practice had the potential for Resident 85's dialysis care not being properly communicated and could put Resident 85 at risk for complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe disposal of a used fentanyl patch (a potent narcotic medication applied to the skin for pain) for one of one resident (Resident 18); and controlled substance (drugs with high potential for abuse or addiction) medications were fully accounted for three out of seven residents (Residents 83, 96, and 107), when medications were signed out of the Control Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented as given to the resident on the medication administration record (MAR). The failure had the potential for accidental exposure and/or diversion of controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility had a medication error rate of 11.11 %, when three medication error out of 27 opportunities during a medication administration for three of 13 sampled residents (Residents 82, 107, and 97) as follows: 1. Resident 82 was given crushed divalproex sodium (brand name: Depakote; medication to treat seizure) ER (extended release, a long-acting form of medication) 2. Resident 107 was given Creon (medication used to treat for people who cannot digest food normally because their pancreas does not make enough enzyme) medication without a meal. 3. Resident 97 been given insulin (medication to lower blood sugar) without priming the needle. These failures had the potential to compromise the residents' medical health and the residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions when: 1. Dietary staff did not cover their hair completely with a hairnet; 2. There was no air gap (space in-between drain spout and the in-floor drain inlet) for the coffee machine drain system; 3. A scoop was stored on top of thickener powder container lid; 4. Mixer had multi-color substances; 5. Can opener gear (part of can opener that is behind the blade) had orange substance; 6. A sick dietary staff did not cover her nose with a face mask while she handled the food; and 7. Three of three ice machines had multi-color substances both interiorly and exteriorly. These failures had the potential to cause foodborne illness for 119 out of 125 residents who consumed the food and ice from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate controlled substance (CS, medications that can be easily abused and are under strict government control) accountability for four of four CS records reviewed (for Residents 86, 95, 227, and 366), when certain counts of CS medications were signed out of the Controlled Drug Record (CDR, an inventory sheet) but were not documented on the Medication Administration Record (MAR) as given to the residents. The failure resulted in the facility not having accurate accountability of CS medications and potential for abuse or misuse of these medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ staff with the appropriate competencies and skills to carry out the functions of the food and nutrition service when: 1. Dietary staff did not know how to calibrate (to adjust a device such as thermometer for its accuracy use) the thermometer for the accurate temperature check; 2. Dietary staff did not know how to correctly check the quaternary sanitizer (sanitizer used to clean kitchen counters, tables and surfaces, and used to manually sanitize dishes). The lack of knowledge regarding food and nutrition services had the potential for dietary staff not being able to carry out their job functions properly and ensure sanitary conditions in the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one non-sampled resident (Resident 37) was not wearing clothing that belonged to another resident. This failure had the potential to negatively affect the resident's dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call buttons were within reach and/or call lights were answered in a timely manner for three of 25 sampled residents (Residents 30, 72 and 166) and five non-sampled residents (Residents 10, 13, 43, 102 and 365). This failure had the potential to result in the residents' needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to verify the preferences for one of five sampled residents (Resident 166) in regards to what types of medical treatments he wanted to receive in the event of an emergency. This failure had the potential to compromise the facility's ability to act in accordance with the resident's wishes during an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 166) received proper assistive device to maintain adequate hearing abilities, and failed to develop and implement a plan of care related to hearing impairment. This deficient practice resulted in Resident 166's limited ability to hear clearly during care and had the potential to negatively affect his psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary assistance to prevent accidents for one of 12 sampled residents (Resident 54). This failure resulted in Resident 54 sustaining a fall with injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary care and services for one of two sampled residents (Resident 219) receiving hemodialysis treatment (medical procedure of removing waste products and excess fluid from the blood through an artificial kidney) when the licensed nurse did not follow-up on the communications from the dialysis center. This failure had the potential to cause the resident health complications and risk for fluid overload.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 107) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medication. Resident 107 received olanzapine (an antipsychotic medication) without an adequate indication, when his behavioral symptoms did not present a danger to himself or to others. Also, Resident 107 did not receive periodic monitoring of the blood lipids while being on olanzapine and simvastatin (medications that would affect the blood lipids). The failure resulted in unnecessary medication for the resident, and inadequate monitoring for potential side effects and effectiveness of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an expired medication was removed from active stock in one of three medication carts inspected; and four opened medications were labeled with an open date in two of three medication carts inspected. The failure had the potential for the residents to receive expired medication; or given medications beyond their effective dates.