Tracy Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan (written plan that guides staff on daily care and safety based on the resident's needs) for one of three sampled residents (Resident 1) to address Resident 1's refusals of care, treatment, and participation in a care conference (a meeting to discuss the resident's plan of care), which prevented Resident 1 from receiving appropriate care, treatment, and care planning. This failure placed Resident 1 at risk for worsening of underlying conditions, overall health decline, and preventable complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to practice appropriate infection prevention and control measures for one of three sampled residents (Resident 2) when two staff members did not perform hand hygiene (cleaning hands with soap and water or alcohol-based hand sanitizer to remove germs and prevent the spread of infection) before and after entering and exiting Resident 2's room to perform care tasks for Resident 2, who was under Enhanced Barrier Precautions (EBP-an infection-control strategy used in nursing homes to help stop the spread of hard-to-treat infection by requiring extra safety steps, such as wearing gowns and gloves during close care). This failure had the potential to spread infection and cause health problems for the residents in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with professional standards for food safety when:1. Items past their use by dates and spoiled food items were stored in the dry storage pantry,2. There was no air gap or back flow prevention device installed for the food prep sink or the three compartment sink (a commercial kitchen essential with three basins for washing, rinsing, and sanitizing dishes),3. The dishwasher chlorine level was below the proper level for sanitizing dishes, and4. Dietary staff (DS) 1 and DS 2 did not perform appropriate hand hygiene while working in the kitchen. These failures had the potential to affect the flavor and palatability of the food and to lead to food borne illness (nausea, vomiting, diarrhea) for the 51 residents receiving facility prepared food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive water safety management program based on nationally accepted standards to minimize the risk of Legionella (bacteria spreads via inhaling contaminated water and can lead to a serious lung infection) and other waterborne pathogens (a microorganism [bacteria] that exists in water sources or plumbing [pipes required for the water supply, heating and sanitation in a building] systems that can cause serious illness in people over [AGE] years of age and those with weakened immune systems) for a census of 52 residents when:a. The facility did not complete and document a facility wide assessment of potential Legionella growth areas to include flow charts;b. The facility did not implement adequate control measures;c. The facility did not establish sufficient monitoring protocols;d. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure four (4) of 20 sampled residents' (Resident 3, Resident 9, Resident 42, and Resident 53) basic grooming needs were met when:Resident 3's fingernails nails were long, jagged, and unclean;Resident 9's fingernails nails were long, jagged, and unclean;Resident 42's fingernails nails were long, jagged, unclean and Resident 42 had an odor coming from her clenched right hand;Resident 53's fingernails nails were long, jagged, and unclean. These failures had the potential for Resident 3, Resident 9, Resident 42, and Resident 53 to sustain injury and/or acquire an infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of twenty sampled residents (Resident 9) was free from unnecessary drugs when Resident 9 was prescribed psychotropic medications (medication that affects behavior, mood, thoughts, or perceptions) and diagnosed with schizophrenia (a serious mental illness that affects how a person thinks, feels and behaves) after admission to the facility. This failure placed Resident 9 at risk of unnecessary psychotropic medication use which could lead to medication side effects, decreased mobility, skin breakdown, and decreased ability to perform self-care tasks.

Inspectors wroteBased on interview, and record review, the facility failed to accurately complete a Pre-admission Screening and Resident Review (PASRR, a required assessment for individuals with mental illness, intellectual or developmental disabilities, or related conditions, so that a determination of need, appropriate setting, and a set of recommendations for services to be included in the individual's plan of care is provided) for 1 of 20 sampled residents (Resident 8) when, Resident 8's level I PASRR did not reflect her diagnosis of bipolar disorder (a mental disorder characterized by periods of extreme mood swings, and causes shifts in mood, energy, activity levels, and concentration), anxiety disorder [a group of mental health conditions that cause fear, dread, and worry), major depressive disorder (a serious mood disorder causing persistent sadness, hopelessness, and loss of interest in [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 20 sampled residents (Resident 9) Preadmission Screening and Resident Review (PASRR, a federally mandated screening of all potential nursing home residents, for mental illness and intellectual disability,to help ensure that individuals are not inappropriately placed in a nursing home, and to ensure they receive any specialized services that are required), form was updated after a significant change in mental illness diagnosis. This failure had the potential for Resident 9 to not receive the necessary care and services required to improve Resident 9's mental health condition and quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide services which met professional standards of quality care for one of 20 sampled residents (Resident 3) when Resident 3 expressed suicidal ideation (thinking about, considering, or planning to end one's life) and no interventions were put in place to monitor her psychosocial needs. This failure had the potential for Resident 3 to make a suicide attempt (try and end one's life) and to negatively affect her psychosocial wellbeing. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication and medical supply storage in the medication cart (a mobile cart with stored medications and supplies needed for administration), refrigerator, and the medication room (a locked room used to store medications and supplies) for a census of 52 residents when:1. When Resident 35's expired Sennosides (a stimulating laxative used to treat constipation) 8.6 milligrams (mg, unit of measurement), and Resident 33's expired Meclizine Hydrochloride 25 mg (an antihistamine used to prevent and treat nausea, vomiting, and dizziness) were stored in the medication cart.2. a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the total actual staffing hours worked Per Patient Day (PPD - a metric system used to measure staffing to resident ratio over 24 hours). This failure could have given a false sense of the facility being adequality staffed to meet the resident's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a total of seven (7) shared resident bedrooms (rooms 1, 3, 5, 8, 10 and 11) measured at least 80 square feet (sq. ft. - unit of measurement) per resident. This failure had the potential to result in a lack of sufficient space for the provision of resident care, to maintain privacy, and to allow for space to house the residents' personal property.

Inspectors wroteBased on interview, and record review, the facility failed to ensure quality of care and services were provided to one of three sampled residents (Resident 1) when cardiopulmonary resuscitation (CPR- an emergency lifesaving procedure performed when the heart stops beating) was not attempted by licensed staff when Resident 1 was found unresponsive on [DATE]. This failure resulted in the wishes for Resident 1's Representative/ Decisionmaker (RR) not being honored and also potentially contributed to the death of Resident 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure preferences for end of life or emergency care would be honored for 3 of 22 sampled residents (Residents 12, 43, 49) when, 1. The facility failed to determine upon admission whether Resident 43 and Resident 49 had an Advance Directive (specific instructions about one's own health care) and, if not, determine whether they wished to formulate an Advance Directive; and, 2. The facility failed to ensure a copy of Resident 12's Advance Directive was available at the facility. These failures could have resulted in the residents' end of life wishes not being honored.

Inspectors wroteBased on interview, and record review, the facility did not ensure correct medications were administered for 1 of 22 sampled residents (Resident 22) when Resident 22 was admitted with the wrong discharging documents from the acute hospital and the error was not identified for three days after admission. This failure placed Resident 22 at risk for complications related to medications received which were not intended for her. and complications related to medications she should have received, but did not for three days.

Inspectors wroteBased on observation, interview, and record review, the facility failed to meet the needs of 1 of 22 sampled residents (Resident 12) when the facility did not adequately follow up on the resident's request for a prosthetic (artificial) leg. This failure had the potential to result in loss of independence, dignity, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a homelike environment was provided for 1 of 22 sampled residents (Resident 55), when Resident 55 did not have enough room to store personal belongings. This deficient practice did not ensure a homelike environment that encouraged the use of personal belongings to the extent possible.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a resident specific care plan (provides direction on the type of nursing care the resident may need based on their health, medication, behavioral, and psychosocial needs) for 1 of 22 sampled residents (Resident 317) when Resident 317 did not have a care plan developed for catheter care. This failure had the potential for care needs not being met for Resident 317.

Inspectors wroteBased on interview, and record review, the facility failed to provide care and services for activities of daily living (ADLs) for 1 of 22 sampled residents (Resident 22) when Resident 22 had no documented evidence a shower was given from 8/6/24 through 8/15/24. This failure had the potential to result in poor hygiene and decreased psychosocial well-being for Resident 22.

Inspectors wroteBased on interview, and record review, the facility did not ensure correct medications were administered and correct plan of care was followed for 1 of 22 sampled residents (Resident 22) when Resident 22 was admitted with wrong discharging documents from the acute hospital and the error was not identified for 3 days after admission. This failure placed Resident 22 to not receive the necessary care and services at time of admission and three days thereafter.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was provided to prevent accidents and hazards for 1 of 22 sampled residents (Resident 62) when the facility did not implement Resident 62's care planned intervention of a wheelchair alarm, and staff did not complete bed alarm checks during the night shift on 7/3/24. This failure could have been a factor in staff not being aware of Resident 62's fall outside, and had the potential increased wandering behavior would not be identified.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two residents (Resident 35) who received parenteral (delivery of medication through a vein) medication was provided services consistent with professional standards of practice when: 1. Resident 35's peripheral IV saline lock (a thin flexible tube placed in a vein in the hand or arm used to give medication and fluids) dressing was not dated; 2. Resident 35 did not have a care plan developed for the IV saline lock; 3. IV site care and flushing for Resident 35's IV saline lock was not documented in the medical record; and, 4. Resident 35's IV saline lock was left in place for eight days. These failures had the potential to increase the risk of infection for Resident 35 and further compromise her health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the controlled medications (highly addictive and regulated medications) for 1 of 22 sampled residents (deceased Resident 58) were removed from the medication cart and the nurses did not count Resident 58's controlled medications at shift change. These failures could have resulted in medication being given to the wrong resident and/or drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 22 sampled residents (Resident 30) received recommended dental services when Resident 30 was not provided the dental treatment recommendation of a full mouth x-ray (a set of pictures that provides images of teeth, gums, and jaw bones) for a broken tooth which was identified on 4/22/24. This failure had the potential to result in health complications for Resident 30 including increased discomfort, infection, problems chewing food, and weight loss.

Inspectors wroteBased on interview, and record review, the facility failed to ensure copies of evaluations were in the resident's medical records for 1 of 22 sampled residents (Resident 12), when the facility did not have access to copies of Resident 12's evaluations for a prosthetic (artificial) leg. This failure had the potential for medical providers not to have reviewed the recommendations regarding acquiring a prosthetic leg for Resident 12.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to maintain infection control measures when: 1. Certified Nurse Assistant (CNA) 10 entered the room of a resident on Contact Isolation Precautions (a type of transmission based precautions intended to prevent the spread of multi-drug resistant organisms [MDRO, germs that are resistant to three or more drugs that kill infection] and other germs that cause infections that are spread by direct or indirect contact with the resident or the resident's environment) without the appropriate personal protective equipment (PPE, gowns, gloves, eye protection, face masks or respirators used to prevent the spread of germs), then exited the room without performing hand hygiene (washing hands with soap and water or using alcohol-based rubs [hand sanitizers] to keep hands clean); 2. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure resident bedrooms measured at least 80 square feet per resident in seven shared rooms. This failure had the potential to limit the personal belongings of each resident and compromise their ability to move freely in their rooms.

Inspectors wroteBased on interview and record review, the facility failed to provide notice of a facility-initiated discharge to the appropriate parties for one of two sampled residents (Resident 1) when, Resident 1 was provided a notice of discharge for failure to pay on 1/3/24 and the notice was not sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman (a patient rights advocate). This failure resulted in the State LTC Ombudsman being uninformed of the discharge decision, removed the opportunity for the State LTC Ombudsman to advocate on Resident 1's behalf, and removed the State LTC Ombudsman awareness of the facility's activities related to discharges.

Inspectors wroteBased on interview and record review, the facility failed to provide notice of a facility-initiated discharge (a resident is given 30 days notice to find another place to live) to the appropriate parties for Resident 1 when, Resident 1's representative (RR, a designated person to make decisions for another person) was provided a notice of discharge on [DATE] and the notice was not sent to a representative of the Office of the State Long-Term Care (LTC) Ombudsman (a resident rights advocator) at the same time. This failure had the potential for the State LTC Ombudsman not being aware of Resident 1's facility initiated transfer/discharge and potentially prevented the opportunity for the State LTC Ombudsman to advocate for resident 1's rights.

Inspectors wroteBased on interview, and record review, the facility failed to provide required supervision for one of three sampled residents, Resident 1, who was dependent on staff for toileting and was left unattended while using the toilet. This failure resulted in Resident 1 attempting to get off the toilet independently without staff supervision which led to a fall and a head injury that resulted in Resident 1's hospitalization on [DATE] and death on [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure needs of the residents were accommodated for two of three sampled residents (Resident 1 and Resident 3), when call lights were not within reach for Resident 1 and Resident 3. This failure had the potential to result in Resident 1 and Resident 3 being unable to ask for needed assistance and placed them at risk for falling.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were used to prevent the spread of germs when: 1. Facility staff and one visitor did not wear protective equipment (such as gowns and gloves) prior to entering the room of a Clostridium-Difficile (C-Diff- a bacteria that causes inflammation of the colon and can be transmitted from person to person by spores) positive resident (Resident 5) and did not perform hand hygiene. 2. Cleaning of a Glucometer (a device for measuring the concentration of sugar in the blood) was not completed after use. 3. Recommended cleaning wipes were not used to clean Resident 5's room. These failures had the potential to spread germs to residents, staff, and visitors within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide restorative (RNA-nursing intervention to increase or maintain resident's mobility and to prevent further decline in mobility) treatment and services to 2 of 19 sampled residents (Resident 13, and Resident 25) when: 1. No interventions were used to address Resident 13's left hand contracture (when muscles, tendons, joints, or other tissues tighten or shorten causing a deformity and loss of movement); and, 2. Range of motion (ROM, the degree of movement that occurs at a given joint during an exercise) exercises were not provided as ordered for Resident 13 and Resident 25. These failures placed Resident 13 and Resident 25 at risk for not maintaining their highest practicable level of physical well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure reconciliation and accountability of controlled medications (medications with high potential for abuse or addiction) and accurate medication administration when, 1. A random controlled medication use audit for Resident 25 did not reconcile. The medication was signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but was not documented on the Medication Administration Record (MAR, a legal document used to record medications given to the residents) on multiple occasions to indicate it was given to Resident 25; and, 2. Resident 38's medications were left unattended and unsupervised on her bedside table. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and supplies were clearly labeled, safely handled, properly stored, and disposed of in accordance with manufacturer guidelines and accepted professional standards for a census of 55 when: 1. An opened bottle of Lorazepam (a medication used to treat anxiety and sleeping problems with high potential for abuse or addiction) was stored in the medication room refrigerator without an opened-date label and initials; 2. A bubble pack (a form of packaging where an individual pushes individually sealed tablets through the foil to remove the medication) of Divalproex Sodium (a medication used to treat certain types of seizures/epilepsy) was stored in medication cart C with no hazardous drug label; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure shared resident bedrooms measured at least 80 square feet (sq. ft.) per resident in a total of 7 resident rooms. This failure had the potential to result in a lack of sufficient space for the provision of resident care, to maintain privacy, and to allow for residents' personal property.

Inspectors wroteBased on interview, record, and facility policy review, the facility failed to ensure 2 of 19 sampled residents (Resident 49 and Resident 34), had a care plan (a formal process which identifies existing needs and recognizes potential needs or risks) developed to address: 1. Resident 49's pressure ulcer (PU-pressure related damage to the skin and underlying tissue) to left (L) heel; and, 2. Resident 34's midline catheter (a catheter inserted into a vein in the upper arm with the tip located just below the armpit). This failure had the potential for Resident 49's and Resident 34's care needs and goals not being addressed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 19 sampled residents (Resident 17), was provided nail care in a timely manner. This failure resulted in Resident 17 having long, and untrimmed fingernails and toenails that could potentially cause injury, pain, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement preventative measures to reduce the risk of elopement (an act or instance when a cognitively impaired person leaves a safe area or premises unsupervised) for 1 of 19 sampled residents (Resident 16) when an elopement assessment was not completed after Resident 16 eloped the facility. This failure placed Resident 16 at an increased risk for elopement and physical harm due to her behavior of wandering in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe medication monitoring for high-risk medication use (drugs with potential to cause harm without monitoring) in 3 out of a sample of 19 residents (Resident 3, Resident 17, and Resident 19) when: 1. Resident 3 was prescribed high risk medications for diabetes (Blood Sugar Disease) without side effect monitoring or guidance for nursing staff for safe use; 2. Resident 17 was prescribed high risk anticoagulant (blood thinner) medications without side effect monitoring or a care plan which addressed specific symptoms to watch for; and, 3. High risk anticoagulant medications were not monitored for side effects on a regular basis for Resident 19. These failures could result in unsafe medication use and adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe cleaning and sanitization of a shared glucometer (a device which measures blood sugar using blood from the fingertip) between resident care for two out of a census of 55 residents (Resident 43 and Resident 48). This failure could result in spread of infection and cross contamination of shared devices.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate use of antibiotic medication (used to treat bacterial infections) within the antibiotic stewardship program, for one of nine residents (Resident 48) when Resident 48's antibiotic order did not have an end date. This failure increased Resident 48's risk for an infection with bacterial organisms resistive to certain antibiotics (MDRO; multidrug-resistant organisms, germs that are resistant to many antibiotics) in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 19 sampled resident's (Resident 34) equipment was in safe operating condition, when Resident 34's call light had an exposed wire. This failure had the potential to affect Resident 34's safety, comfort, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure direct care staffing information was posted in a prominent place as required for a census of 55. This failure prevented the residents and visitors from viewing the hours and number of direct care staff providing care to the residents of the facility on a daily basis.