VI at Palo Alto

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Kitchen Staff F (KS F) used proper technique when testing sanitizer concentration for cleaning food contact surfaces. This failure had the potential to increase the risk of contamination and exposure to food borne illness for 37 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive care plans were developed and revised timely for two of 12 sampled residents (Residents 30 and 7) when: 1. Resident 30's Care Plan indicated Full Code and the physician's order indicated DNR;2a. Resident 7's Care Plan indicated Full Code and the POLST indicated DNR; and2b. Resident 7's Care Plan did not indicate self-administration of medication. These failures had the potential to affect the provision of care.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacy consultant's medication regimen review recommendation for one of 12 sampled residents (Resident 1). This failure had the potential to affect the safety and management of the resident's medication regimen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when inspection of two of three medication carts identified an insulin pen without a visible resident's name on it. This failure had the potential for the unlabeled insulin to be administered to the wrong resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when the shared glucometer was not sanitized and disinfected for one out of two sampled residents. This failure could result in cross-contamination and the spread of infection throughout the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their restraint protocol and ensure the proper use of side rails or bed canes (adjustable rigid bars attached to the side of a bed) for nine (Residents 1, 12, 22, 26, 32, 33, 191, 243, and 246) of 24 residents (residents who used side rails or bed canes) when: 1. Resident 1 there was no physician order, side rail assessment, consent, or care plan for the use of side rails; 2. For Resident 243 there was no physician order or care plan for the use of bed canes; 3. For Resident 246 there was no physician order for the use of bed canes; 4. For Resident 191 there was no physician order or care plan for the use of bed canes; 5. For Resident 12 there was no physician order or consent for the use of bed canes; 6. For Resident 22 there was no consent for the use of bed canes; 7. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored in accordance with professional standards for food safety when: 1. There was an opened undated food item in the pantry freezer; 2. There were open and undated food items, and unopened food items with no expiration dates in the dry storage area of the main kitchen. These failures had the potential to cause food contamination and food-borne illness to 37 of 37 residents who received their food from the kitchen. 1. During an initial kitchen tour on 8/19/24 at 9:20 a.m., accompanied by the Executive Chef (EC), inside the reach-in freezer there was an opened, undated container of mango sorbet. The EC confirmed the sorbet was opened and not dated and he stated all items should have been dated when opened. The EC stated the mango sorbet must be discarded. 2. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to protect the rights of residents to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service) when staff members left the computer screen open and unattended in the hallways of resident care areas. This deficient practice had the potential to compromise the rights of the residents to privacy and confidentiality.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate pharmaceutical services when there were discrepancies between the controlled drug (those with high potential for abuse and addiction) record (CDR, an inventory/accountability sheet) and the medication administration record (MAR) for two out of two residents (Residents 140 and 26). This failure resulted in the facility not having accountability of controlled medications, which had the potential for misuse or diversion.

Inspectors wroteBased on observation, interview and record review, the facility had a facility medication error rate of 7.59% when two medication errors occurred out of 26 opportunities during medication administration for two out of 5 residents (Resident 21 and Resident 32). This failure resulted in medication not given in accordance with the prescriber's orders which resulted in residents not receiving the full therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control practices for two out of two sampled residents when: 1) A Licensed Vocational Nurse E (LVN E) did not disinfect a glucometer after using it to test a resident's blood sugar (Resident 32). 2) A Registered Nurse C (RN C) did not scrub the hub (an endcap) at the end of a peripherally-inserted central catheter (PICC, a type of tube that goes directly to the heart) line for 15 seconds before flushing the PICC line with normal saline solution and before connecting the intravenous (IV) drug tubing to the PICC line (Resident 191). 3) RN D did not wear gloves when removing a medicated patch from a resident's chest, then did not wear gloves or perform hand hygiene when applying a new medicated patch to the resident's chest (Resident 15). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate assessment and supervision to prevent an accident for one of three residents (Resident 1) when physical therapy (PT, a healthcare profession that helps you move better or strengthen weakened muscles) did not follow physician's orders to assess Resident 1's functional ability level upon admission and develop a resident-centered plan of care. This resulted in Resident 1's fall, head injuries, multiple fractures, and subsequent death.

Inspectors wroteBased on interview and record review, the facility failed to ensure an environment free of accidents when one of three sampled residents (Resident 1) fell during mechanical lift transfer. This failure resulted in Resident 1 sustaining lots of bruises to the body and had been feeling fearful during transfers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was stored and prepared under sanitary conditions when: 1. There were unlabeled and undated food items in the kitchen refrigerator and blast chiller (equipment that quickly lowers food temperature); 2. There were dented cans of food in the dry storage area of the kitchen; 3. There was a black substance on the inside of one out of two ice machines; and 4. Kitchen attendant B (KA B) did not follow printed instructions when testing the surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to cause food contamination and illness for all residents who received food from the kitchen (34 of 35 residents).

Inspectors wroteBased on interview and record review, the facility failed to provide and/or document restorative nursing assistant (RNA) treatments for one of five sampled residents (Resident 26). This failure had the potential to result in functional decline for Resident 26.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer oxygen in accordance with professional standards of practice for one of two sampled residents (Resident 5), when her oxygen humidifier bottle (a bottle filled with water connected to the oxygen source to keep the airways moist) was empty and oxygen humidifier bottle was not changed weekly. These failures had the potential to affect the residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for two of 12 sampled residents (Resident 5 and 24) when: 1. The licensed nurse irrigated the left and right nephrostomy (an artificial opening created between the kidneys and the skin to facilitate urine drainage) tubes with one syringe; and 2. The licensed nurse did not perform hand hygiene between tasks. These failures had the potential for the development and the spread of infections in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement the antibiotic stewardship program (program intended to prevent the overuse of antibiotics) for one of three sample residents (Resident 26). Resident 26 received a course of antibiotics, but did not meet the criteria for antibiotic treatment. This failure had the potential to increase the prevalence of multi-drug resistant organisms in the facility.