Veterans Home of California - Yountville - SNF

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that food safety and sanitation guidelines were followed when multiple expired food items were found in the dry storage and refrigerator of the main and satellite kitchen. These failures posed the risk for food-borne illnesses (a sickness caused by consuming food, or drinks contaminated with harmful substances) in a medically fragile population of 162.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the recommendations identified in the Level II PASRR (Preadmission Screening and Resident Review- used to ensure individuals are placed in an appropriate setting and receive needed mental health services) evaluation were implemented into the comprehensive care plan and resident care for one of 33 sampled residents (Resident 15). This failure resulted in Resident 15 not receiving the necessary specialized services and support identified through the PASRR process, placing Resident 15 at risk for unmet mental health needs, decline in Activities of Daily Living's (ADL- essential, basic self-care tasks done every day such as bathing, dressing, eating and moving around.) and diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Care Plan was updated on one (1) of 33 sampled residents, when Resident 160 complained of swallowing difficulty. This failure had the potential to result in life-threatening outcomes including fatal aspiration pneumonia, choking, severe dehydration, and malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services to maintain or improve Activities of Daily Living (ADLs- essential, basic self-care tasks done every day such as bathing, dressing, eating and moving around) for five (5) of 33 sampled residents (Residents 15, 105, 97, 40, and 69) when:1. Resident 15 did not receive Occupational Therapy (OT) services in accordance with the physician order. This failure resulted in functional decline in ADLs.2. Residents 105, 97, 40, and 69 did not receive daily partial baths in accordance with the facility's policy and procedure (P&P). This failure placed residents at risk for poor hygiene, including body odors that can lead to social withdrawal, depression and significant emotional distress. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (1) of 33 sampled residents (Resident 97), Resident 97's food tray matched the meal ticket. This failure had the potential to result in malnutrition and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention practices for two of 33 sampled residents (Resident 16 and 171) when:1. Certified Nursing Assistant (CNA) 3 was observed in Resident 171's room without the required Personnel Protective Equipment (PPE-gear worn to minimize exposure to illnesses) for Enhanced Droplet Precaution (EDP- strict rules used to prevent spread of serious illnesses that travel through the air).2. Certified Nursing Assistant (CNA) 4 was observed transferring Resident 16 from the bed to the wheelchair without the required Personnel Protective Equipment (PPE-gear worn to minimize exposure to illnesses) for Enhanced Barrier Precaution (EBP- infection control intervention designed to reduce the transmission of infections in nursing homes).

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure food was palatable in regard to temperature, flavor, and texture. This failure had the potential to result in decreased food intake resulting in food related medical complications for 144 residents, who received food from the kitchen.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety when: 1. The facility did not have a system in place to ensure all hot food was reheated to a minimum of 165 degrees Fahrenheit (F) and all cold food was held at or below 41 degrees F; 2. Three air vents located in the dish room and food production area in the Main Kitchen (where food was prepared for the licensed care kitchen), were not clean; 3. Supervisory staff did not cover facial hair in the kitchen where food was stored and handled; 4. Trays used for food service were in poor condition; and 5. An industrial can opener was not clean and stored available for use. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1. Controlled substance medications (medication with a high potential for abuse and addiction) were accurately accounted for on the medication administration record (MAR) and the Controlled Drug Record (CDR) for four of five randomly selected residents (Residents 16, 75, 81, and 128); 2. To establish an accurate system to limit the diversion of narcotic medications designated for destruction by nursing staff; 3. To follow its policy and procedure (P&P) for the management of resident medications for out-on-pass (OOP) status and develop a system to include reconciliation of the last administered dose of medications upon the resident's return. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure expired medications were not available for resident use; 2. Opened multi-dose biologicals were dated with an opened or discard date to ensure they were not used beyond the expiration date. The deficient practices had the potential for residents to receive medications with unsafe and reduced potency from being used past their expiration date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment when: 1. Three of five staff (Contract Staff [CS] 1, Certified Nursing Assistant [CNA] 6, and Custodian Worker [HSK] 1) did not perform hand hygiene or utilize personal protective equipment (PPE- equipment worn to minimize exposure to infectious or hazardous materials, e.g. gown, gloves, mask, eye protection) in accordance with policy and procedure and nationally recognized infection prevention and control guidelines. 2. One of one custodian worker (HSK 1) did not follow facility procedure for the cleaning and disinfection of an occupied room. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 31) remained free from restraint when Resident 31's bed was placed against the wall with four bedrails in the upright position and the bedside table positioned over Resident 31's body. This failure had the potential to obstruct Resident 31's mobility and cause injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 57's medication was documented when Registered Nurse (RN) 6 did not document medications were given. This failure had the potential to cause negative health-related outcomes to Resident 57.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain a walk-in freezer when there was a large amount of ice build-up on the ceiling as well as ice build-up on boxes of food. The failure to maintain one freezer in one out of two kitchens had the potential to result in decreased quality and contamination of food.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment by ensuring the safety of their residents for one of three sampled residents when Resident 1 was found dead outside the facility basement exit door.

Inspectors wroteF-580 Notification of Changes Based on interview and record review the facility failed to immediately notify the physician of a significant change of condition in Resident 1's breathing status with life threatening clinical complications warranting a transfer to the hospital. This failure resulted in a delay of care for Resident 1.

Inspectors wroteBased on interview and record review the facility failed to ensure the Doctor on Call (DOC 1) responded promptly to the notification of Resident 1's change of condition by nursing staff. This failure resulted in nursing staff not having the guidance of a physician to manage Resident 1's change of condition and transport to the emergency department.

Inspectors wroteBased on interview and record review the facility failed to document complete and accurate records of assessments and interventions provided to Resident 1 during his change in medical condition. This failure resulted in Resident 1's medical records being incomplete and inaccurate.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and follow their policy and procedure Missing resident and Elopement - Code Purple (SNF / ICF), for one of two sampled residents (Resident 1) when Resident 1 signed out of the unit and did not specify where he was going and gone for two days. The assigned nurse was aware that Resident 1 was out of the unit all night and didn't alert anyone. Unit staff initiated the policy for missing resident and elopement on the following day. These failures placed Resident 1's safety at risk for accidents, injuries, and resulted in Resident 1 going without scheduled and as needed medications for two days while he was at a motel in a nearby city.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. Live roaches were found in a sticky trap on the floor under the stainless-steel counter in the nourishment area, behind the ice machine, in the room with the 3-compartment sink, and in the dish washing room of the staging kitchen of the [NAME] Building. Pests are capable of transmitting disease to humans by contaminating food and food-contact surfaces. 2. Floor under the counter tops had food crumbs and trash in the nourishment area, behind the ice machines, under the tray line assembly (where staff serve the food on plates for the residents), and in the house keeping closet in the staging kitchen in the [NAME] Building. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program when a roach infestation in the [NAME] staging kitchen persisted since 6/8/23, unsanitary conditions were observed that provide harborage conditions for pests (cross-reference F 812) and pests were being allowed entry into the kitchen. This had the potential for pests to transmit disease to residents by contaminating food and food-contact surfaces for 197 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations for one of 35 sampled residents, Resident 120, and unsampled Residents 9, 185, and 64, by failing to ensure call lights were within reach in the restrooms. This failure had the potential to result in residents unable to request assistance when needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean environment when: 1. A visibly soiled wheelchair was stored in a hallway. 2. Staff did not clean the lift equipment after use. These failures had the potential to result in spreading disease causing organisms to residents using the unclean equipment.

Inspectors wroteBased on interview and record review, the facility failed to determine one of 35 sampled residents, (Resident 159) required a Significant Change in Status Assessment (SCSA) within 14 days of a significant decline with the Minimum Data Set (MDS, a standardized assessment tool that measures health status in nursing home residents) when Resident 159 had an: 1. Emergence of a new unstageable (unable to determine where the injury begins and ends) pressure injury. 2. Emergence of unplanned weight loss problem. This failure had the potential to further complicate Resident 159's medical status as the facility did not convene in a timely manner to address interdisciplinary measures from the care team.

Inspectors wroteBased on observation, interview and record review, the facility failed to update the comprehensive care plan for Resident 120 that accurately stated assistive devices resident required. This failure resulted in the inability to track resident progress to provide continued comprehensive care for one of 35 sampled residents, Resident 120.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for one of 35 sampled residents (Resident 99) when Resident 99's wound care orders were changed. This failure had the potential for miscommunication among staff and for Resident 99 to receive care that was no longer required, and to delay wound healing.

Inspectors wroteBased on interview and record review, the facility failed to provide facility sponsored community activities for one of 35 sampled residents (Resident 80). This failure had the potential to prevent Resident 80 from obtaining a meaningful connection with his community and improving his quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 35 sampled residents (Resident 597 and Resident 71) received the following: 1a. Resident 597 failed to receive timely cardiology (branch of medicine that deals with diseases and abnormalities of the heart) follow up after a fall as ordered by the Physician. This failure had the potential to adversely affect Resident 597's medical condition. 1b. Resident 597's referral to neurosurgery (medical specialty that diagnosis and treats diseases/disorders of the spine) was completed, as recommended by the Physician. This failure had the potential to adversely affect Resident 597's medical condition. 2. Resident 71's compression stockings were not changed regularly or when visibly soiled. This failure had the potential for Resident 71 to acquire skin irritation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an audiology assessment was conducted and right hearing aid was replaced in a timely manner for one of 35 sampled residents (Resident 120). This failure resulted in Resident 120 not receiving an audiology (branch of science and medicine concerned with the sense of hearing) assessment and replacement of the hearing aid.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide Physical Therapy (PT) per physician's order in a timely manner for one of 35 sampled residents (Resident 120). This failure resulted in delay of care (greater than one month) for Resident 120, that contributed to prolonged use of wheelchair and decline in mobility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a discontinued Novolin R Insulin Sliding Scale (dose of insulin based on blood glucose level) was not carried over to the current physician's order for one of 35 sampled residents (Resident 79). This failure had the potential for medication administration error.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were properly stored when Resident 43's Voltaren (a topical medication for pain) was found stored without a cap in a container with other residents medications. This failure had the potential to result in medication contamination and compromised effectiveness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain Transmission Based Precautions (infection control precautions) for one of 35 sampled residents (Resident 156) and one unsampled resident (Resident 130) when: 1. An Xray Technician (XT) did not wear the required Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards) while providing care for Resident 156, who was on droplet isolation precautions (measures used to protect residents, staff, and visitors from exposure with infectious agents). 2. Resident 130 was exposed to contaminated Personal Protective Equipment (PPE, equipment worn to minimize exposure to hazards), when placement of a PPE disposal bin obstructed the path to his bed. These failures had the potential to result in cross-contamination and the spread of infectious diseases to residents, staff and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with a safe, functional, sanitary, and comfortable environment when: 1. Unit [NAME] 1D had visibly soiled windows in the entry hallway. 2. In room [ROOM NUMBER], a urinal was unlabeled and undated for Resident 188. These failures resulted in an unsafe and unsanitary environment for the residents.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents (Resident 1) had an updated Care Plan. This failure had the potential to place Resident 1 at risk for preventable falls and potential injury.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three sampled residents (Resident 1) was 1.) Provided a timely occupational therapy (OT) evaluation. 2.) Followed occupation therapy recommendations for care. This failure led to several potentially preventable falls for Resident 1 and had the potential for additional falls and injury.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were accurately documented for 1of 1 sampled residents (Resident 1) when Resident 1's medical record contained numerous inaccurate entries. This failure resulted in health information and diagnoses that did not pertain to Resident 1 and had the potential that planning of patient care and treatment could be effected.