The Terraces of Los Gatos

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 sampled residents (Resident 1) when there was no documentation that licensed nurses notified the physician that Resident 1 did not receive multiple medications. Failure to notify the physician had the potential to result in additional orders not being received and carried out as needed.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered for one of three sampled residents (Resident 1) because the medications were not available in the facility. This failure had the potential to compromise Resident 1 ' s health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders for one of three residents (Resident 1) when: 1. A physician order for Resident 1's use of an abduction pillow (device used to separate the legs and stabilize the hips) was not carried out upon admission to the facility; and, 2. The facility staff failed to transcribe the physician orders for hip precautions (restrictions for after having a total hip replacement), and use of an abduction hip brace (device to maintain correct body alignment and reduce the risk of dislocation) on the Treatment Administration Record (TAR). These failures prevented the Resident 1 from receiving the necessary treatment prescribed by the physician and had the potential for joint repair dislocation, which would jeopardize the rehabilitation of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to develop an individualized resident-centered care plan to address Resident 1's physician orders for total hip precautions (restrictions for after having total hip replacement) and use of an abductor (to position the leg away from the midline of the body) hip brace. These failures had the potential to result in the inability to identify Resident 1's individualized care issues and implement person-centered care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of practice when: 1. Staff did not implement the facility's policy for four of seven residents (Residents 163, 166, 59 and 209) with pacemakers or automatic implantable cardioverter-defibrillators (surgically implanted devices that help control the heartbeat); and 2. Staff did not implement the facility's protocol after discovering a skin discoloration for one of 13 sampled residents (Resident 24). These failures had the potential to negatively affect the residents' health, safety and well-being.

Inspectors wroteBased on interview and record review, the facility failed to monitor the side effects related to the use of Eliquis (an anticoagulant [blood thinner] medication that interrupts the formation of blood clots) for three of 13 sampled residents (Residents 11, 16 and 6). This failure had the potential to affect the residents' physical well-being while in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food under sanitary conditions when: 1. Two kitchen personnel were not wearing hair nets and one kitchen staff's hair was not completely covered; 2. Thawed chicken in the walk-in refrigerator was undated; 3. Dried tomatoes were not discarded by the good thru date on the label; 4. A box of popcorn kernels in the dry storage was not tightly sealed; and 5. Wild rice and a bottle of mayonnaise did not have an expiration date on the label. These failures had the potential to cause food borne illnesses to the residents in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement infection control and prevention practices when: 1. Certified nursing assistant A (CNA A) was not screened for Coronavirus Disease 2019 (COVID-19, a contagious viral infection that can cause severe respiratory symptoms) before entering the facility and providing resident care; 2. Staff did not perform hand hygiene and medical equipment sanitization during medication pass; 3. Staff did not change gloves between tasks; and 4. Staff did not change Q-tips and did not label a dressing during wound treatment. These failures had the potential to result in transmission and spread of infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures for reporting and investigation of allegations of abuse for one of 13 sampled residents (Resident 1) when Resident 1's abuse allegation was not reported and investigated. These failures had the potential to result in the abuse recurrence to residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the discharge Minimum Data Set (MDS, an assessment tool) for one of three residents (Resident 57). Failure to accurately assess had the potential to compromise the facility's ability to provide resident-centered discharge care planning and interventions for the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to completely assess two of 13 sampled residents (Residents 1 and 209) after fall incidents when: 1. For Resident 1, the facility did not do fall risk assessments after two falls; and 2. For Resident 209, the facility did not complete post-fall assessments after three falls. These failures had the potential to increase the recurrence of falls and to compromise the facility's ability to anticipate and implement interventions to prevent future falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care in accordance with professional standards of practice for two of 13 sampled residents (Residents 163 and 4) when: 1. For Resident 163, the facility did not implement its policy regarding continuous positive airway pressure (CPAP, device that uses a hose connected to a mask to deliver air and keep the airway open during sleep) and did not develop a care plan to address his use of a CPAP machine. Also for Resident 163, the facility did not store his oxygen tubing according to policy. 2. For Resident 4, the facility did not develop a care plan to address her use of oxygen. Failure to implement the CPAP policy compromised the facility's ability to ensure Resident 163 was receiving the correct amount of air pressure to keep his airway open during sleep. [...]

Inspectors wroteBased on interview and record review, the facility failed to monitor for side effects and target behaviors (behaviors intended to be changed or eliminated by medications) for one of seven residents (Resident 163) who received psychotropic medications (medications that cause changes in mood, feelings or behavior). This failure had the potential to compromise the facility's ability to determine if the psychotropic medications were effective. This failure also put Resident 163 at risk for experiencing harmful effects from the medications.

Inspectors wroteBased on observation, interview and record review, the facility had a 7.69% medication error rate when two medication errors out of 26 opportunities were observed during medication passes for two of six residents (Residents 16 and 3). These failures resulted in medications not being given in accordance with the prescriber's orders and/or manufacturer's specifications, which could have resulted in the residents not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to label medications in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, in one of two medication carts. This failure had the potential to result in administration of expired medications.

Inspectors wroteBased on interview and record review, the facility failed to designate an Infection Preventionist (IP) that had completed specialized training in infection prevention and control when their current IP did not have an IP certificate. This failure had the potential to compromise the facility's infection prevention and control programs (IPCP) for the residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow their pressure ulcer (PU, ijuries to skin and underlying tissue resulting when soft tissue is compressed between a bony prominence and an external surface for a long period of time) prevention policy for one of two sampled residents (Resident 16) with a PU. The facility did not plan for or implement the intervention to protect Resident 16's left heel from undue pressure by keeping it off of the bed. This failure resulted in Resident 16 developing a facility-acquired Stage III PU (involves full-thickness skin loss and extends into the tissue beneath the skin, forming a small crater) on his left heel.

Inspectors wroteBased on observation, interview and record review the facility failed to plan for and implement new post-fall interventions to prevent falls for one of six sampled residents (Resident 4) with falls. These failures resulted in Resident 4 falling six times between 4/17/19 and 8/15/19, and on the sixth fall, Resident 4 sustained a right hip fracture.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection prevention practices were followed for five of 51 residents ( Residents 16, 32, 110, 111, and 108 ) when: 1. For Residents 16 and 32, a staff did not perform proper glove technique during wound treatment. 2. For Residents 110, 111, and 108 a staff did not perform hand hygiene during dining observation. These deficient practices had the potential to spread infection.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification to the long-term care ombudsman (person who routinely visits the facility and advocates for the residents) when three of five sampled residents (Residents 32, 4, and 34) were transferred to the acute care hospital. This failure had the potential to result in the residents not having an advocate who could inform them of their admission, transfer, and discharge rights and options.

Inspectors wroteBased on interview and record review, the facility failed to provide a written notice of bed hold (written documentation specifying the duration the facility will hold a resident's bed) for four of five sampled residents (Residents 21, 32, 4, and 34). This failure had the potential to limit the rights of the resident or his responsible party (RP, a person who is accountable in making decisions on behalf of the resident) to know the duration of a bed-hold and permitting for return to the facility.

Inspectors wroteBased on observation , interview and record review, the facility failed to develop a comprehensive care plan to address the use of antibiotics (medicines that help stop infections caused by bacteria) and a peripherally-inserted central catheter (PICC, a thin, flexible tube that is inserted into a vein in the upper arm and guided (threaded) into a large vein above the right side of the heart and used to give intravenous fluids, blood transfusions and other drugs) for one sampled resident (Resident 105). These failures had the potential to result in the inability to identify the residents' individualized care issues and implement person-centered care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive interdisciplinary plan of care for three of four sampled residents (Residents 15, 4, and 33) was revised to reflect the resident's current care needs and interventions. This posed the risk of not providing residents with individualized and person-centered care.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy and procedures for the use of a continuous positive airway pressure (CPAP, a treatment that uses mild air pressure to keep your breathing airways open) machine for one sampled resident (Resident 107) when Resident 107 was using the CPAP machine without a physician's order. These failures had the potential to result in ineffective CPAP therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided consistent with a person-centered care plan and the resident's goals and preferences to one of three residents (Resident 213). This failure had the potential to result in ineffective pain management.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals when: 1. One of three emergency kits was not replaced in a timely manner; 2. An ordered medication for Resident 213 was not available; 3. The process of receipt and disposition of controlled drugs did not allow for accurate reconciliation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was reviewed and reassessed by the multidisciplinary team (IDT, team members from different departments involved in a resident's care) for one of six residents (Resident 4). Resident 4 had an order for narcotic pain medication (controlled drugs that in moderate doses dulls the senses, relives pain, and induces profound sleep but in excessive pain assessments dose can cause stupors, coma, and convulsions) three times a day with meals and at bedtime. This had the potential of unnecessary use of medications that could affect the resident's well-being.

Inspectors wroteBased on interview and record review, the facility failed to adequately monitor the side effects of psychotropic drugs for two of six residents (Residents 9 and 109). This failure had the potential to result in staff not identifying adverse consequences in residents.

Inspectors wroteBased on observation, interview and document review, the facility failed to store medications in a safe manner when nursing staff left the medication refrigerator unlocked. This failure had the potential to allow residents and unauthorized staff to access medications.