The Terraces at Los Altos Health Facility

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen when:There were whitish substances below the steamer and on a metal cart in front of the steamer; 2. There were whitish-grayish substances on a black cart in the dry storage area that was used to store utensils and food containers; 3. There were whitish substances on the edges of the food warmer cart in the dry storage area; 4. There were two open packs of brown grapes and one pack of raw broccoli that were unlabeled and undated in the walk-in refrigerator; 5. There were whitish substances on the outside surface of the ice machine; and, 6. Nine cutting boards were discolored, worn out, and had deep cuts and scratches. These failures had the potential to result in foodborne illness in a population of vulnerable residents with complex medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the discharge Minimum Data Set (MDS, an assessment tool) for four of seven residents (Residents 46, 76, 105, and 2) . Failure to complete and transmit MDS assessments had the potential to compromise the accuracy of the facility's quality measures (reports that reflect the facility's performance in certain care areas). This could negatively affect the facility's ability to identify areas for improvement and implement interventions accordingly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:1. A nebulizer machine (device used to deliver medication in the form of a mist for inhalation) mask, chamber (part of the mask that holds the liquid medication), and tubing were stored inside the bedside drawer of resident 127 and the mask was touching the drawer surface;2. An inhaler chamber attachment (device that attaches to an inhaler to make it easier to breath the medication in) had a yellowish substance around the mouthpiece and was stored on top of resident 2's bedside table;3. Garbage and recycle bins were open and exposed while three Residents were eating lunch; 4. A licensed nurse did not wear gloves when holding and cutting a medication; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of five sampled residents (Residents 82, 111, and 118) were free from unnecessary psychotropic medications (medications that cause changes in mood, feelings, or behavior) when:For Resident 82, his order for quetiapine fumarate (medication used to treat psychotic disorders) did not specify what dose do administer;For Resident 111, there was no documentation that staff were monitoring for side effects of venlafaxine (medication used to treat depression); andFor Resident 118, there was no documentation that staff were monitoring for side effects and target behaviors (behaviors intended to be changed or eliminated by the medication) for trazodone (medication used to treat depression). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the long-term care Ombudsman (resident advocate) was notified of transfers or discharges for two of four residents (Residents 82 and 2). For Resident 2, the facility also failed to ensure a discharge summary was completed. Failure to notify the Ombudsman had the potential to compromise the residents' admission, transfer, and discharge rights. Failure to complete a discharge summary had the potential to compromise the facility's ability to ensure the resident received appropriate care and services after leaving the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for one of thirteen sampled Residents (Resident 127). This failure resulted in a delayed plan of care for Resident 127.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement care plans for one of 13 sampled residents (Resident 35) when a care plan for Nystop External Powder (a brand name for topical nystatin, an antifungal medication used to treat skin infections caused by yeast) was not developed. This failure had the potential to not meet the residents' medical, nursing, mental and psychosocial needs. Review of Resident 35's medical record indicated she was admitted to the facility on [DATE] and had diagnoses including difficulty in walking, cellulitis (a skin infection) of left and right lower limbs (lower legs), hypertension (high blood pressure), and chronic venous hypertension (CVH, a condition where the veins in the legs experience elevated, persistent pressure due to impaired blood flow back to the heart) with inflammation of bilateral lower extremities (legs). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 19 residents (Residents 119, 120, and 114) were free from unnecessary medications when:Resident 119 had no side effects monitoring for heparin (an anticoagulant [blood thinner] used to decrease the clotting ability of the blood and help prevent harmful clots from forming in blood vessels); 2. Resident 120 had three identical orders for oxycodone (a potent controlled medication for pain); and 3. Resident 114 had no side effects monitoring for Eliquis (an anticoagulant medication used to treat and prevent blood clots). These failures resulted in unmonitored side effects of anticoagulant medications and duplicate orders that had the potential for excessive dose/adverse effects for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 6.9% when two medication errors occurred out of 29 opportunities during the medication administration for two out of 12 residents (Residents 111 and 67) when:1. For Resident 111, Registered Nurse B (RN B) did not follow a physician's order to hold midodrine (medication used to raise blood pressure) for systolic blood pressure (SBP, the top number in a blood pressure reading) greater than 120; and2. For Resident 67, Registered Nurse C (RN C) administered eyedrops and did not wait three to four minutes before instilling a second drop in each eye. These failures had the potential to result in the residents experiencing complications and not receiving the full therapeutic effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly in one medication cart and for two of 13 sampled residents (Resident 35 and 127) when:1. Two expired bottles of over the counter medication (OTC) medications were not removed from the medication cart;2. A bottle of Nystop External Powder (a brand name for topical nystatin, an antifungal medication used to treat skin infections caused by yeast) was kept on Resident 35's bedside table unattended; and,3. A bottle of Nitroglycerine sublingual tablets (a fast-acting medication used to relieve and prevent chest pain) was kept on resident 127's bedside table unattended. These failures had the potential for unsafe and improper administration of medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for two of 13 sampled residents (Residents 82 and 119) when:For Resident 82, there was a typographical error in his order to monitor urine output; and,For Resident 119, the medical record did not accurately reflect the resident's refusal of a lab test. These failures had the potential to compromise the care and safety of the residents.1. Review of Resident's 82's medical record indicated he was admitted on [DATE] and had diagnoses including bladder cancer, hydronephrosis (swelling of the kidneys caused by a backup of urine), and kidney failure. Further review of the medical record indicated Resident 82 had nephrostomy tubes (small flexible tubes inserted through the skin and into the kidneys to drain urine) in both kidneys. [...]

Inspectors wroteBased on interview and record review, the facility's interdisciplinary team (IDT, team composed of members from different departments involved in resident's care) failed to review and revise the fall risk care plan after a fall incident for one of four residents (Resident 1). This failure had the potential to result in Resident 1 experiencing further falls.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the correct administration of medication when the licensed vocational nurse A entered the medication order to the wrong resident. This failure resulted in one of three sampled residents (Resident 1) receiving a medication that was not prescribed for this resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three residents (Resident 1) when: 1. medications were not administered as ordered by the physician; and, 2. Resident 1's physician was not informed regarding missed doses of medication. These failures had the potential to compromise Resident 1's health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to offer and/or attempt alternatives, explain risks and benefits, or obtain informed consent prior to the use of side rails in accordance with their bed rails (side rails, safety rails, and grab/assist bars) policy for 25 of 25 residents (137, 80, 16, 23, 179, 180, 181, 182, 14, 4, 138, 10, 18, 130, 11, 2, 12, 7, 6, 129, 131, 133, 136, 132, 30). These failures had the potential to place the residents at risk of entrapment and serious injury. For Resident 30, it resulted in the resident's left hand getting caught between the mattress and quarter [one-fourth, one part of a whole divided into four equal parts] side bed rail.

Inspectors wroteBased on observation, interview, and record review, the facilty failed to ensure sanitary conditions were maintained in the kitchen when: 1. Kitchen staff did not wear hair restraints while in the kitchen; 2. A red bucket was stored on the floor 3. A dietary aide picked up an item from floor and did not perform proper hand hygiene 4. Three of three ice machines had white residue or scale (the buildup of a white, chalk-like substance that forms where water collects or where water is dispensed) . These failures had the potential to cause food contamination and spread food-borne illness to residents who received their food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported to the proper agencies per the facility's abuse policy for one of two residents (Resident 23) when Resident 23's abuse allegation was not reported after surveyor notified the administrator (ADM) and executive director (ED). This failure left information relevant to an allegation of abuse unreported to agencies required to be reported to for such allegations.

Inspectors wroteBased on interview and record review, the facility failed to follow a physician's order for one of three sampled residents (Resident 180) when weekly weights were not done as ordered by the physician. This failure of not following a physician's order resulted in the facility to be unaware of Resident 180's weight for over two weeks.

Inspectors wroteBased on interview and record review, the facility failed to prevent a pressure ulcer (damage to the skin caused by prolonged pressure) from developing for one of two residents (Resident 12) when a medical device was not placed properly. This failure resulted in a facility-acquired pressure ulcer for Resident 12.

Inspectors wroteBased on observation, interview, and record review the facility failed to 1. administer all physician ordered medications to one of three residents (Resident 2) when his Miconazole nitrate 2% topical cream (antifungal cream) was not administered during medication administration, and 2. ensure proper accounting of the controlled medication oxycodone (a semi-synthetic narcotic analgesic drug to relieve pain) in one of two medication carts (med cart 1) when the count of the oxycodone whole tablet (tab) and half tab were not correct. These failures had actual (for Resident 2) and potential implications for residents to not receive their prescribed medication(s) correctly.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (Residents 130 and 131) were free from unnecessary psychotropic (drug that affects brain activities associated with mental processes and behavior) medications. 1. For Resident 130, there was no side effect monitoring and behavior monitoring for the use of trazodone (medication used to treat depression or help with sleep problems); 2. For Resident 131, there was no side effect monitoring and behavior monitoring for the use of trazodone. These failures had the potential to result in lack of adequate monitoring and for the residents to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention strategies when: 1. A nurse did not change gloves and perform hand hygiene during one of two dressing changes. 2. One of three urinary catheter bags was on the ground. These failures had the potential to spread infectious organisms to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 7) was offered and/or received influenza (a contagious respiratory illness caused by influenza viruses that infect the nose, throat, and sometimes the lungs) and pneumococcal (common bacteria that can affect different parts of the body) vaccinations. This failure increased the potential to for residents to have inadequate immunity to influenza and pneumococcal infections.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure: 1. Two routine pain medications were obtained and administered, as ordered, to meet the needs for one of three sampled residents (Resident 1). The nursing staff failed to call the pharmacy to clarify order changes, and to notify the physician when they ran out of the medications for administration. The failure exposed Resident 1 to unnecessary pain; 2. Two of two controlled medication (those with high potential for abuse and addiction) emergency kits (E-kit: a kit/box containing medications and supplies for immediate use during a medical emergency) were locked in the medication room. This had the potential for loss or abuse of controlled medications; and 3. One of two opened E-kits was replaced timely to ensure availability of medications for resident use in case of an emergency.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors when Resident 1 did not recieve two routine pain medications as prescribed. The failure exposed Resident 1 to unnecessary pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately when: 1. One of one medication refrigerator was identified unlocked when not in use; and its temperature was not being monitored and maintained twice daily as per facility policy and procedures (P&P). This failure could lead to loss of medications, and loss of drug potency due unmonitored temperatures; 2. An opened multi-dose vial did not have an open date. The failure had the potential for the medication being used past its effective date.

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 is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, document that specifies the medical treatments the resident wants to receive during serious illness) was completed for 7 of 17 sampled residents (Residents 17, 21, 25, 26, 232, 329 and 330). These failures could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes.

Inspectors wrote2. Review of Resident 14's clinical record indicated he was admitted to the facility on [DATE]. Resident 14 was transferred to the acute hospital on 1/27/23 due to a fever and altered mental status and again on 2/24/23 for critically low hemoglobin (protein in red blood cells that carries oxygen in the bloodstream). Review of Resident 280's clinical record indicated he was admitted to the facility on [DATE]. Resident 280 was transferred to the acute care hospital on [DATE] after sustaining a fall resulting in uncontrolled back pain. Review of Resident 280's clinical record indicated he was discharged from the facility on 12/21/22. Resident 280 was discharged home with home health services. Review of Resident 282's clinical record indicated she was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the controlled substance counting (medications with high potential for abuse or addiction) sign-off sheets for every shift were initialed by license nurses when: Narcotic sign-off sheets were missing initials by licensed nurses for medication carts 1 and 2 This failure had the potential to result in loss, misuse, and accountability for controlled substances.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food safety when: 1. There were opened undated, unlabeled, and outdated food items in the reach-in refrigerator and dry storage areas; 2. Pans and plastic containers used for food preparation and food service were stacked and stored wet; 3. Kitchen staff did not know the proper procedures for testing chlorine (chemical) sanitizer used for dishwashing; 4. The dishwasher sanitizing log was not completed; 5. There were no logs recording weekly calibration of thermometers; 6. The temperature of a food item on the steam table was not checked prior to serving during lunch; 7. A scoop was left inside the flour container; 8. There were dented cans of food in the dry storage area; 9. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection prevention protocols were followed during multiple occasions, when 1. hand hygiene was not performed between glove changes during wound care, 2. proper PPE (personal protective equipment, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) was not worn inside of an isolation room, and 3. hand hygiene was not used during medication pass. These failures had the potential of causing personal and wide spread infections, compromising the health and well-being of all residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) on medications self-administration (residents take medications without staff assistance) and bed side medications storage for two out of 12 sampled residents (Resident 1 and Resident 231) when (a) the facility did not determine that residents were clinically appropriate and safe to self-administer medications, (b) the facility did not ensure self-administered medications were stored in a safe and secure place, and (c)The facility did not obtain a physician order to store medications at bedside. These failures had the potential to result in unsafe medication self-administration. These failures also had the potential to result in other residents gaining unapproved access to the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the admission baseline care plan for one of 12 residents (Resident 10) was developed in a timely manner, when Resident 10's baseline care plan was not developed within 48 hours of their admission. This failure had the potential of the resident not getting the care she needed and thus having a negative impact on their health and well-being.

Inspectors wroteBased on interview and record review the facility failed to develop and implement person centered and individualized care plans for three out of seventeen sampled residents (Resident 16, 329, and 19) when: 1. Resident 16 had a fall; 2. Resident 329 had a fall and an allegation of abuse, and 3. For Resident 19 there was no care developed after a fall. These failures may delay the implementation of the interventions, identification of specific care areas and services to meet the resident's needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to provide care and services according to accepted standards of clinical practice for one of three residents (Resident 25) when: Resident 25's room air oxygen concentrator (RAOC-a machine takes room air and passes it through the filtering system in the machine and converts it to more pure oxygen) was set to deliver oxygen flow at a rate of 3.5 liters per minute (L/min, oxygen flowing into nostrils over a period of one minute) via nasal cannula when Resident 25 had an order for oxygen at 2 liters per minute. This failure had the potential to compromise Resident 25's health and well - being, and not meeting the resident's therapeutic needs or excessive use of oxygen.

Inspectors wroteBased on interview and record review, the facility failed to ensure two out of five residents (Residents 12 and 279) were free from unnecessary medication when: 1. Resident 12 had physician orders which did not have an indication for the use of Risperdal, a psychotropic (any drug that affects behavior, mood, thoughts, or perception) medication, there was no monitoring of her behaviors, and there was no informed consent for the Risperdal. 2. Resident 279 had physician orders which did not have an indication for the use of Seroquel, there was no monitoring of her behaviors, and there was no informed consent for the Seroquel. These failures had the potential of residents receiving psychotropic medications without a need for them.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility's medication error rate did not exceed five percent or greater when observation of 30 opportunities during the medication administration resulted in two errors (both for Resident 15). The calculation of medication error rate was 6.67 percent. These failures placed Resident 15 at risk for not receiving the full therapeutic effects of medications when medications were not given according to physician's orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medication when: One opened and undated tuberculin purified protein derivative (PPD- a solution used for tuberculin skin test) multi-dose vial was observed in the refrigerator in the medication storage room; This failure had the potential for residents to receive a PPD skin test with reduced potency due to the drug to be potentially past its use-by-date.