The Terraces at San Joaquin Gardens Village

Inspectors wroteBased on interview and record review the facility failed to meet professional standards of practice for one of four sampled residents (Resident 1) when Resident 1 ' s family member reported Resident 1 ' s abuse allegation to a licensed nurse (LN) and the LN perform a resident assessment and document on an SBAR (situation, background, assessment, recommendation- a communication tool used by healthcare workers when there is a change of condition among the residents) note in the electronic medical record (EMR) according to the facility ' s policy and procedure (P&P). This failure placed Resident 1 ' s safety at risk by not assessing her for signs and symptoms of potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe and sanitary environment when the facility's three tumble dryers in the laundry room was not maintained per the manufacturer's recommendations and had a layer of gray and white debris collected on the back of the dryer's vent and pipes. This failure had the potential to create a fire hazard that could have placed 50 of 50 residents at risk for displacement.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for three of 10 sampled residents (Resident 17, 197, 247) when: 1. Resident 17 had broken teeth and visible signs of tooth decay and no specific care plan interventions were put in place to address Resident 17's dental needs. This failure had the potential to result in Resident 17's dental needs to not be met which placed Resident 17 at an increased to develop dental infection. 2. Resident 197 and 247's care plans did not include their physician prescribed oxygen therapy (the administration of oxygen at concentrations greater than that of ambient air (20.9%) with the intent of treating or preventing the symptoms and manifestations of hypoxia-decreased perfusion of oxygen to the tissues). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for two of five sampled residents (Resident 347 and Resident 24) when: 1. Resident 347 did not have a care plan for the use of sling to left arm and splint to left foot. These failures placed Resident 347 at risk for complication from not having care plan needs planned by licensed nurses to determine if nursing interventions needed to be added, changed or completed. 2. Resident 24 did not have a care plan for the use of antibiotic for clostridium difficile (C-diff-germ that causes diarrhea and colitis [inflammation of the colon]). This failure placed Resident 24 at risk for care needs not met.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of practice for two of five sampled residents (Residents' 98 and 247) when: 1. Resident 98's oxygen (a colorless, odorless, tasteless gas essential to living organism) flow rate (the amount of oxygen being delivered to the body) was not administered according to the physician order. This failure resulted in Resident 98 to not receive the ordered amount of oxygen via oxygen concentrator (a machine that pulls in oxygen from the surrounding air) which could lead to breathing problems which includes shortness of breath, headache and confusion. 2. Resident 247's oxygen flow rate was set to 1.5L (liters-a unit of measurement) instead of the physician prescribed 2L/minute. [...]

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure all medications used in the facility were properly labeled and discarded after the discontinued date when: 1. In the west wing medication cart, Resident 36's discontinued ondansetron (medication used for nausea and vomiting) was not separated from active medications 2. In the south wing medication cart, Resident 37's discontinued benzonatate (medication used for cough) was not separated from active medications and Resident 98's insulin lispro (medication used to lower blood sugar) multidose vial was stored in medication cart, partially used and not labeled with an open or discard date. These failures had the potential for medications to be administered incorrectly causing an underdosing or overdosing of medications, or to be administered to the wrong residents causing harm to the residents.

Inspectors wrote3. During a concurrent observation and interview on 3/17/25 at 4 p.m. with Resident 98 in her room, Resident 98 was in semi-sitting position in bed watching TV and stated she did not know how long she had been in the facility. Observed in the room next to Resident 98 bed was a nasal cannula on the floor under a bedside chair and connected to a oxygen concentrator (device that produces oxygen for breathing). Resident 98 stated she used the oxygen every day and had difficulty breathing without the oxygen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status of one of five sampled residents (Resident 98) when Resident 98's surgical wound was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 98's care needs to not be met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary drugs for two of six randomly sampled residents when: 1. Resident 12 was administered ondansetron (a medication for nausea) and had active orders for both routine and as needed (prn) ondansetron, which exceeded the maximum daily dose (maximum dose in 24 hours). 2. Staff administered apixaban (a blood thinner) to Resident 24, but did not monitor for side effects of apixaban. These failures had the potential for Resident 12 to experience ondansetron toxicity including irregular heartbeat, and for Resident 24 to experience apixaban side effects including bleeding.

Inspectors wroteDuring an interview and record review, the facility failed to ensure one of five randomly sampled residents (Resident 12) was free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when the facility did not have an objective goal for number of behavioral episodes of escitalopram (medication used to treat depression) care planned for adequate monitoring and did not attempt a gradual dose reduction, when Resident 12 was administered escitalopram. These failures had the potential for Resident 12 to experience falls, sedation (sleepiness), fatigue, muscle cramps, and increased potential for Resident 12 to be isolated.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care or referred to a dental hygienist to address dental needs for one of five sampled residents (Resident 17) when Resident 17 was admitted with poor dentition characterized by visible signs of decay and missing and broken teeth and the facility did not ensure Resident 17 was referred and assessed timely by a dental hygienist to address her dental needs This failure resulted in Resident 17 reporting feelings of embarrassment due to her dental condition and placed Resident 17 at an increased to develop dental infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed for one of three sampled residents (Resident 198) when Resident 198 was served roasted red potatoes while on a mechanical soft-chopped diet. This failure placed Resident 198 at risk for choking.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan for three of four sampled residents (Residents 1, 2 and 3) when Residents 1, 2 and 3 did not have a care plan addressing the residents ' food allergies. This failure placed Residents 1, 2 and 3 at risk for being served foods they were allergic to and had the potential for a severe anaphylactic reaction (extreme, life-threatening allergic reaction). (cross reference F806)

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was served food that accommodated the resident ' s allergies (when the immune system [defends the body against harmful substances] overreacts to a food triggering a protective response) and intolerances when Resident 1 with a documented shrimp allergy was served shrimp for lunch on 8/19/24. This failure resulted in Resident 1 experiencing an allergic reaction causing nausea, vomiting, and abdominal pain and required a transfer to the emergency department (ED) by ambulance for treatment. (cross reference 657)

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of six sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice when Licensed Vocational Nurse (LVN) 1 discharged Resident 1 home with seven medications which belonged to Resident 2. This failure resulted in Resident 1 not being administered her prescribed blood pressure medications for four days as prescribed by the physician and placed Resident 1 at risk for adverse effects of medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services which ensured appropriate administration and disposal of medications to meet residents needs when: 1. 3. Nursing staff administered and failed to clarify Resident 243's pancrelipase (medication containing enzymes for those that have pancreatic problems) medication order lacked appropriate instructions to administer with meals. Nursing staff administered and failed to clarify Resident 240 and Resident 242's midodrine (medication given to raise blood pressure) medication orders with inappropriate hold parameters. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that four out of four residents (Residents 10, 11, 14 and 15) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 26 opportunities during the medication pass resulted in five errors. The calculated medication error rate was 19.23%. These failures resulted in: 1. Placing Resident 23 at risk of a stroke (damage to the brain caused by a blockage or bleeding) and blood clots when Licensed Vocational Nurse (LVN) 5 administered a chewable Aspirin (drug that reduces blood clotting, fever, pain and inflammation) tablet instead of the prescribed Aspirin Delayed Release (DR- a medication designed to release the active ingredients later after it is taken) tablet. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications used in the facility were properly labeled and discarded after the expiration date or discontinued date when: 1. In the East Wing medication storage room, discharged Resident 244's carboxymethylcellulose sodium eye drops (eye moisturizer and lubricant), white petrolatum-mineral oil eye drops, hypromellose eye drops, and nasal spray were found in the patient own med bin not separated from for residents currently in the facility. 2. In the [NAME] Wing medication cart, Resident 19's discontinued lactulose (medication used to treat constipation and liver disease) 10 GM (gram- unit of measurement)/15 ML (milliliter- unit of measurement) solution bottle was found not separated from medications that were in use for facility residents. 3. [...]

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 service safety when: 1. One of two dry storage pantries had two boxes of instant cereal, one box of dry yeast, three cans of black olives and two jars of dill pickles did not have a received by and expiration date. 2. One of two dry storage pantries had a large plastic container of flour with an open ill-fitting lid. 3. One of two freezer storages had a large plastic container of ice cream with an open ill-fitting lid. These failures placed residents at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records for residents that were complete, accurately documented and readily accessible for seven of nine sampled residents (Resident 15, 18, 17, 33, 11, 31, and 10) when a copy of the Physician Orders for Life-Sustaining Treatment (POLST) forms (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) were incomplete and not readily available as part of the residents' medical record. These failures had the potential risk for Residents 15, 18, 17, 33, 11, 31, and 10's end-of-life care decisions to not be followed in case of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with dignity and respect for one of three sampled residents (Resident 16) when Resident 16's urinary catheter (is a tube that is inserted into the bladder, allowing the urine to drain freely) bag was not covered and was visible to the public while Resident 16 was in her room. This failure violated Resident 16's privacy to ensure dignity and respect which resulted in Resident 16's urinary catheter bag to be visible to other residents and visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan (individualized plan of care to document patient needs and potential risks, to work collaboratively toward optimal outcomes) within 48 hours of admission for one of five sampled residents (Resident 18) when Resident 18 did not have a care plan for diabetes mellitus (chronic condition with persistently high blood sugar level). This failure placed Resident 18 at risk for hyperglycemia (high blood sugar) and ketoacidosis (a life-threatening complication of diabetes).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for 10 of 10 sampled Residents (145, 146, 25, 1, 28, 40, 31, 201, 197, and 34) when: 1. Resident 145 experienced a severe unplanned weight gain of 25.2 pounds (lbs-measurement of weight), or 10% of previous weight, in two days. Weights were obtained but were not communicated to the Physician and Registered Dietitian (RD) to determine effective interventions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service when: 1. A systematic process was not used to ensure meats were thawed properly, 2. Resident dishes were not washed to prevent cross contamination, 3. One of three ice machines was not clean, 4. Hair restraints were not worn during food service activities, 5. Frozen foods were not stored to prevent freezer burn, and 6. Food preparation equipment was not air dried. These failures had the potential for the growth of microorganisms which can result in food borne illnesses in a highly susceptible resident population of 46 facility residents that consumed food prepared in the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services which met professional standards of quality for one of three sampled residents (Residents 199) when Resident 199's enoxaparin (medication used to prevent blood clot) injection site was not rotated. This failure placed Resident 199 at risk of developing skin bruising and scarring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grooming needs were met for one of three sampled residents (Resident 195) when Certified Nursing Assistants (CNAs) failed to assist Resident 195 with her shaving. This failure resulted in Resident 195 's hygiene care needs being unmet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of three sampled residents (Resident 200) when Licensed Vocational Nurse (LVN) 1 did not assess Resident 200's pain prior to administering acetaminophen (pain medication). This failure had the potential for Resident 200 to experience pain without adequate pain relief.

Inspectors wroteBased on observation and interview, the facility failed to ensure two of 46 sampled residents received pureed foods that were prepared by methods to conserve nutritive value, when puree food items were cooked more than one and a half hours prior to meal service. This failure placed residents receiving a pureed diet at risk for compromised nutritional status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form to meet resident needs for one sampled resident (Resident 18) when Resident 18 did not received thickened liquids as ordered. This failure placed Resident 18 at risk for aspiration (when food or liquids are breathed into the lungs).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their contingency plan (backup plan to protect residents from being exposed to COVID-19) for employees who were granted COVID-19 vaccination exemptions when one of six employees exempted from receiving the COVID-19 vaccination (Cook 1) was not wearing an N95 mask that fit properly and was not wearing a face mask or goggles while he prepared, cooked, and delivered food throughout the facility; and [NAME] 1 had never been fit tested (a test to ensure a specific brand/type of N95 mask creates a proper seal with a specific person's face to ensure protection). This failure placed all residents at risk for exposure to COVID-19 by an unvaccinated employee which could lead to hospitalization, severe illness, and death.