Tampico Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure comprehensive skin assessment was conducted and pressure injury (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) prevention for one of two sampled residents (Resident 1) when:Resident 1's skin injury on the right buttock, described as a bump with purple discoloration, did not have the exact measurements and specific anatomical (structure of the body) location documented. Resident 1's cause of skin injury was not investigated. Resident 1's physician's order to apply preventive boot for Stage I (skin intact with redness) pressure injury on left heel was not implemented. This failure placed Resident 1 at risk for further skin breakdown, infection, and delayed wound healing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure for one out of four residents (Resident 1), the accuracy of data collection during respiratory illness outbreak. Resident 1 was not included in respiratory illness outbreak line list (infection control tracking tool used to collect data and active monitoring of both residents and staff during suspected outbreak). This failure resulted in unreliable data for analysis and identifying the root cause of infection.

Inspectors wroteBased on observation interview and record review the facility failed to observe infection control measures for Residents 1,2 and 3 when the following items were found in the shared room sink of Residents 1, 2 and 3:a. One open, unlabeled toothbrush exposed to air and one tube of unlabeled toothpaste were stored in an unlabeled kidney basin (Kidney basin is a shallow, kidney-shaped tray, also known as an emesis basin or kidney dish, used in medical settings to collect bodily fluids like urine or vomit, medical waste, and surgical supplies). b. One unlabeled open tube of triad paste was stored together with two open, unlabeled tubes of toothpastes in a kidney basin (Triad paste is a cream applied to various wounds, including pressure ulcers of the residents). These deficient practices had the potential to transmit infectious microorganisms among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pureed texture meal was prepared in a manner that is flavorful, appetizing, and with good nutritional value. These failures had the potential to affect the resident's overall nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food served was palatable and at proper temperature. The oven BBQ beef roast was dry and non-tender, the vegetables were bland, and cheddar biscuit was dry. These failures had the potential to affect resident's well-being due to lack of enjoyment, satisfaction, and decrease in nutrients from their meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in safe and sanitary manner when, large baking sheet trays with ground meat patties were not fully covered and stored near fresh vegetables, and foods were stored without identifying labels and use-by-dates. These failures had the potential for contamination of food resulting in food borne illness.

Inspectors wroteBased on observation, interview and record review, the skilled nursing facility staff did not honor personal choices for one of 26 sampled residents (Resident 51). Resident 51 had complained to staff that his bed was not long enough and he wanted regular utensils with his meals as opposed to the plastic ones being served. Staff did not abide by his requests. This resulted in Resident 51 feeling Frustrated.

Inspectors wroteBased on observation, interview and record review the facility failed to provide reasonable accommodations and/or alternative measures to address visual deficit (partial or total inability of visual perception) for one sampled resident (Resident 112). This failure caused Resident 112 to become tearful and feel worthless.

Inspectors wroteBased on interview and record review the skilled nursing facility staff did not accurately assess the needs for one of 26 sampled residents (Resident 51). Resident 51 had difficulty eating with poor-fitting dentures and impaired vision due to broken eyeglasses. This resulted in Resident 51 feeling Frustrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 88), foot care on a regular basis. Resident 88 had long, thickened, and cracked toenails, and his feet and ankles had layers of scaly dry skin. This failure resulted in Resident 88's feelings of well-being being affected due to lack of foot care.

Inspectors wroteBased on interview and record review, the skilled nursing facility's licensed nursing staff did not provide care according to professional standards for 2 of 26 sampled residents (Residents 90 and 111). Residents 90 and 111 had elevated blood pressures that were not treated with available medication or reported to the doctor. This resulted in the potential for a stroke. (bleed or clot in the brain)

Inspectors wroteBased on interview and record review the skilled nursing facility did not make an appointment to assess poor vision for one of 26 sampled residents (Resident 51). Resident 51 had broken his glasses and could not adequately see. This resulted in Resident 51 feeling Frustrated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for one out of 26 sampled residents (Resident 99), Resident 99's head of the bed (HOB) was elevated at a minimum of 30 degrees during tube feeding administration. This failure had a potential to affect Resident 99's health due to accidental inhalation of stomach contents to lungs.

Inspectors wroteBased on observation, interview and record review, the facility failed to label medications and properly dispose of expired medications for two of 26 sampled residents (Residents 24 and 28): 1. Resident 24's one open inhaler (inhaler: a devise used for delivering medicines into the lungs through breathing) was used beyond the use by date. 2. Resident 28's one discontinued inhaler was found in the medication cart. This failure exposed Resident 24 in receiving an inhaler with questionable potency and efficacy. This failure also resulted in a lack of oversight for Resident 28's discontinued inhaler.

Inspectors wroteBased on observation, interview and record review, the skilled nursing facility's staff did not set up a dental appointment for one of 26 sampled residents (Resident 51). Resident 51 had no natural teeth and had poor fitting dentures. This resulted in Resident 51 feeling Frustrated.

Inspectors wroteThe facility failed to assist one out of three sampled residents (Resident 73) obtain Medi-Cal authorization for dental services in a timely manner. This failure had the potential to cause Resident 73 to be without dentures longer than necessary, which could result in weight loss, unhappiness, and stress.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (Resident 1 and 3) of three sampled residents were free from verbal and physical abuse when, 1. Resident 2 screamed, hit and made verbal threats to harm Resident 1 during an altercation in the hallway; and 2. Resident 2 threw an object at Resident 3 who reacted by pushing the table, lost his balance and fell at a bingo game in the dining room. This failure caused repeated resident-to-resident altercations, emotional distress and potential to result in injuries for residents in the facility. Findings 1. Review of Resident 2 ' s progress notes dated 3/12/24 indicated Resident 2 screamed, hit and made verbal threats to harm Resident 1. Resident 2 was angry that Resident 1 was in the room next to Resident 2. Resident 2 demanded that Resident 1 leave her side of the hallway. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from physical abuse when Resident 2 punched her roommate (Resident 1) on the left arm with her right hand. This failure had the potential for physical injury from retaliation in response to the roommates's aggressive behavior.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff followed policies and procedures for safe medication administration when: 1. For one (Resident 5) of five sampled residents, Registered Nurse 1 (RN 1) left six prescription medications on Resident 5 ' s bedside table unmonitored. 2. For three of five sampled residents (Resident 5, Resident 2, and Resident 4), nursing staff did not use two resident identifiers (Information directly associated with a person that reliably identifies the individual as the person for whom the service or treatment is intended) before administration of medications. The failure to monitor the medications left on Resident 5 ' s bedside table resulted in Resident 5 taking medications prescribed for another resident and required two days in an acute care hospital to monitor Resident 5 for adverse side effects from the medications. [...]

Inspectors wroteBased on observation, interview, and record review, for one of four sampled residents (Resident 5), the facility failed to ensure nursing staff followed policy and procedures to prevent significant medication errors when nursing staff failed to use resident identifiers (Information directly associated with a person that reliably identifies the individual as the person for whom the service or treatment is intended) to check Resident 5 ' s identity before leaving six medications not prescribed for Resident 5, on Resident 5 ' s bedside table. [...]

Inspectors wroteBased on observation, interview, and record review, for two of two sampled residents (Resident 1 and Resident 2), the facility failed to ensure a homelike environment with clean bed and bath linens that are in good condition when facility did not have enough towels and bed linens and used washcloths that had frayed edges. This failure resulted in an unfamiliar and uncomfortable environment for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and procure food in a sanitary manner when eggs were not pasteurized, dented cans were stored in the dry storage area, and a scoop used for a thickening agent was not stored in its holder. These deficient practices had the potential to cause food borne illness that can affect all residents. The facility census was 79.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow the lunch menu planned for 12/6/22 when fruit cups was served as dessert instead of triple fruit crisp. This deficient practice resulted in Resident 26 feeling disappointed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow infection control policies and procedures when two residents (Resident 189 and 28) of four sampled residents receiving oxygen therapy aerosol set-ups were not labeled and put away in a manner to prevent infection. This deficient practice has the potential to spread infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, assess, and intervene for multiple purplish discolorations on the right and left arms of one of 23 sampled Residents (Resident 28). This failure placed Resident 28 at risk for further skin injury and delayed care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of 23 sampled residents (Resident 59). This failure resulted in Resident 59 feeling upset that her room was not homelike.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (Resident 46) of five sampled residents with mobility issues received treatment and care to prevent a worsening of contractures (a condition of shortening and hardening of muscles, tendons, or other tissues, often leading to deformity and rigidity of joints) when Resident 46 did not receive Restorative Nursing Program (RNA) services. This deficient practice has the potential for Resident 46 contractures to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedures for oxygen administration for one (Resident 23) of four sampled residents receiving oxygen therapy when two portable oxygen tanks were not safely stored. This deficient practice may result in placing individuals in the facility at risk of potential harm in the event that a portable oxygen tank is dropped.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare food that was palatable and attractive when Resident 26 was served a burnt quesadilla for lunch. This deficient practice resulted in Resident 26 not enjoying her lunch and feeling disappointed.

Inspectors wroteBased on observation, interview and record review, the facility had a 7.14 % medication error rate when two medication errors of 28 opportunities were observed during medication passes observation: 1. Reglan 5 mg (metoclopramide- use to treat nausea, vomiting) was given with meals. 2. Staff did not follow physician order to mix Prostat (a liquid protein for pressure ulcers, wounds, critical illnesses and other conditions requiring increased protein) 30 milliliters with 100 milliliters. These failures had the potential of ineffective medication treatment for Residents 19 and 69.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. a male kitchen staff did not wear facial hair protection while in the kitchen food preparation areas; 2. several food items were expired; 3. canned emergency food supplies were dented; 4. expired nutritional supplements were stored with currently used enteral (food fed via a tube) products. These failures had the potential to cause food contamination or food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices when: 1. The staff did not change gloves during treatment for Resident 40. 2. The staff did not wash hands before and between glove changes during treatment for Resident 19. 3. The staff did not wash hands before and after delivering meal tray to Residents. 4. The staff did not wash hands between residents during medication pass for Resident 69 and 84. These failures increased the potential for cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 40) was treated with respect and dignity when staff failed to close the privacy curtain during treatment procedure. This failure had the potential to result in Resident 40's unnecessary body exposure, and embarrassment that could lower her self-stem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to provide notice to the Office of the Long-Term Care Ombudsman of transfers to the hospital for two of 22 sampled residents (Residents 66 and 76). This failure had the potential to result in the residents not having access to an advocate.

Inspectors wroteBased on observation, interview and record review, the facility failed to to provide pain management for one (Resident 25) of 22 sampled residents when: 1. a pain assessment was not conducted routinely. 2. pain medication or non-drug intervention was not given for complaints of pain. These failures resulted in unnecessary pain and suffering which affected Resident 25's ability to maintain his highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, for one (Resident 25) of 22 sampled residents, the facility failed to ensure that Resident 25 was free of a significant medication error when a scheduled antibiotic medication was not given. This failure had the potential for Resident 25 not getting the full effect of the antibiotic and compromise the healing process.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage when: 1. in the North Wing Station medication room, the refrigerator had a yellowish sticky liquid at the bottom and the container for the medications to be destroyed was overflowing. 2. in the South Wing Station medication room, the refrigerator had a yellowish sticky liquid at the bottom. 3. the South Wing Station Medication Cart 3 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart; the pill crusher was with brownish substance around the rim. Discontinued medication for Resident 83 was still stored it the Medication Cart 3. 4. in the South Wing Station, Medication cart 1 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart and pill crusher had brownish substance around the rim. [...]