Watsonville Post Acute Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Certified Nursing Assistant E (CNA E) wore gloves when providing toilet hygiene and bed bath to Resident 20 who was on enhanced barrier precautions (EBP, an infection control strategy for healthcare settings, especially nursing homes, to reduce the spread of multidrug-resistant organisms - MDROs, germs that are resistant to many antibiotics - by requiring healthcare personnel to wear gowns and gloves during all high-contact resident care activities); 2. Licensed vocation nurse B (LVN B) did not sanitize her hands when she went from Resident 58's room to Resident 31's room; 3. The oxygen filters of Resident 31's, Resident 49's, Resident 58's, and Resident 60's oxygen concentrators were dirty, and the filter boxes were not dated; 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that meet professional standards for two of 20 residents (2 and 54) when:1. Registered nurse A (RN A) left two tablets of lanthanum carbonate (used to treat too much phosphate in the blood) with Resident 54 and did not observe Resident 54 taking the medication during meds administration; and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 22.22% when 6 medication errors occurred out of 27 opportunities during medication administrations for four out of 8 residents (2, 3, 6, and 54). This failure resulted in medications not given in accordance with the prescriber's orders which resulted in residents not receiving the therapeutic effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food serving items were air-dried prior to stacking them, when serving trays and plate covers were observed to be wet while stacked. This failure had the potential of causing food-borne illnesses in the resident population of those who ate food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (7) receive care and services for the provision of dialysis (procedure to remove waste or toxins from the blood and adjust fluid and electrolyte imbalances) consistent with professional standards of quality when licensed vocational nurse B (LVN B) did not check Resident 7's bruit (an audible vascular sound associated with turbulent blood flow usually heard with the stethoscope). These failures had the potential for delayed detection, reporting, and management of complications from the dialysis shunt for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored appropriately when overused-by date insulin was found in Station 3 medication cart. This failure resulted in the overused-by date insulin being administered to Resident 32.

Inspectors wroteBased on interview and record review, the facility failed to implement fall-related interventions for one of two residents (Resident 32) when staff did not document Resident 32's skid mat (non-slip material) was in place on 6/17/23, when staff did not ensure Resident 32's sensor pad alarm (device that emits an audible alarm when pressure is removed from the sensor pad to alert the caregivers; such as, when the user gets out of a bed or wheelchair) orders were transcribed in the administration records for nurses to document pad placement and functioning, and when the facility failed to provide evidence of periodic staff training on the operation of the sensor pad alarm and daily device testing of the sensor pad alarm per manufacturer's recommendations. [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement care plans (a plan that provides direction on the type of nursing care the individual may need) for two of 19 sampled residents (38 and 66): 1. For Resident 38, there was no care plan that addressed the long term care of her gastrostomy tube (g-tube, a surgical opening into the stomach for administration of nutrition and medications), no care plan developed for the use of an anticoagulant (a medication that prevents or reduces blood from clotting); and, 2. For Resident 66, a care plan for diabetes was not developed. These failures had the potential for the facility to overlook care issues and render person-centered care plans lacking measures to address identified needs.

Inspectors wrote2. The Controlled Drug Records (CDRs) for six random residents receiving PRN (as needed) controlled medications were requested for review during the survey. Review of Resident 47's CDR for Lorazepam 0.5 milligrams (mg, unit of measurement) indicated nursing staff signed out one tablet on 2/19/24, 2/20/24, and 2/24/24. Review of Resident 47's physician's orders indicated he had a previous physician's order for Lorazepam 0.5 milligrams to be administered every twelve hours as needed for anxiety with an end date of 2/14/24. It also indicated he had a current physician order for Lorazepam 0.5 milligrams to be administered every twelve hours as needed for anxiety with a start date of 2/26/24. During an interview with registered nurse H (RN H) on 3/6/24 at 3:21 p.m., RN H confirmed Resident 47 did not have a physician order for Lorazepam from 2/15/24 to 2/25/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications when: 1. An open box of tuberculin (use for skin test to determine exposure to tuberculosis) vial found in the medication refrigerator did not have an open date on the vial; 2. Medications were not properly labeled and stored in one of two inspected medication storage rooms; and, 3. Multiple loose tablets were observed in the two drawers of one medication cart. These failures had the potential for residents to receive medications with reduced efficacy, inadequately monitored medications, and unlabeled medications, which could compromise residents' health and safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of 19 sampled residents (Resident 38), was provided the necessary care to maintain good grooming and personal hygiene. This failure resulted in Resident 38 not receiving fingernail care and had the potential for infection and to negatively impact Resident 38's overall health.

Inspectors wroteBased on interview and record review, the facility failed to monitor the side effects related to the use of Apixaban (an anticoagulant [blood thinner] medication that interrupts the formation of blood clots) for one of 19 sampled residents (Residents 38). 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 ensure expired food items were not stored in the residents' refrigerator readily available for use when two boxes of Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition) was found unlabeled and expired in the residents' refrigerator. This failure had the potential to result in contaminated food and foodborne illnesses to an already vulnerable facility population.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to ensure infection control practices were followed for one of three residents (Resident 293) when licensed vocational nurse A (LVN A) did not perform hand hygiene during medication administration. This failure had the potential for transmition of infectious agents to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the competency of the two of two staff, the Registered Dietitian (RD) and the Dietary Services Supervisor (DSS), responsible for oversight of Food and Nutrition Services, when: 1. The RD did not provide consultation to the DSS regarding multiple kitchen sanitation issues (cross-reference F812); 2. The RD did not provide consultation regarding the palatability and consistency of food texture; 3. The DSS did not report multiple maintenance issues she was aware of including: a. a leaking reach-in refrigerator; and b. a reach-in freezer with significant ice build-up, 4. The DSS did not have a reliable system for ensuring staff cleaned according to the cleaning schedule; 5. The DSS and the RD did not ensure the juice machine was maintained in a clean and sanitary manner. 6. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure palatability and nutritive value of cooked foods were maintained when vegetables were cooked for an extended time. In addition, one resident (Resident 78) complained about food being overcooked. This failure had the potential to result in decreased palatability; leading to a decrease in food consumed by residents, and food cooked for extended time periods could lose nutritive value leading to a decreased nutrient intake for 90 residents who received food from the kitchen. Findings On 12/6/2021 at 9:21 a.m., during an observation and interview with [NAME] 1 and Dietary Services Supervisor (DSS), indicated pans in a hot oven covered with foil. [NAME] 1 stated the items in the oven were pureed meat and pureed vegetables cooking in the oven for lunch time. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was stored, prepared, and served in a sanitary manner when: a. The wood shelving under a preparation table was dirty and in poor condition; b. Cooking pans ready for use had a significant amount of residue build-up, were significantly scratched on the cooking surface, and had non-stick coating peeling off; c. The floor area around a reach-in refrigerator and under a preparation table had a significant amount of residue build-up and cobwebs; d. Knives for food preparation had residue on the blades, the blades came into contact with dirty wire covers, and were stored directly under an insect killer machine which had a fly on the surface; e. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the proper upkeep, maintenance, and safe operating conditions of the kitchen appliances: 1. dairy reach-in refrigerator 2. multi-door reach-in freezer These failures had the potential to attract pests (cross-reference F-925) and impact the ability of the equipment to operate as intended leading to improper storage of food resulting in food that is not safe and/or poor quality for 90 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an effective pest control program to ensure a pest free environment when the facility had flying black bugs in the kitchen. This failure had the potential to cross-contaminate food and utensils leading to illness for 90 residents who received food from the kitchen. Findings During observation on 12/6/2021 at 9:39 a.m., a small black fly was observed on the underside of the bug extermination machine, which was mounted above the clean, ready for use, knives. During an observation and concurrent interview on 12/6/2021 at 9:45 a.m., with the Dietary Services Supervisor (DSS), she showed a reach-in refrigerator holding dairy products had a significant amount of thick residue at the base of the front, near the floor. The thick residue was orange, brown, and black in color. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an advance directive (AD, a written instruction, such as a living will or durable power of attorney for health care when the individual is incapacitated) or Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patients' treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) was available and completed for five of five residents (8, 33, 54, 282, and 283) reviewed under the advance directive care area. These failures had the potential to result with inability to make medical decisions when residents cannot make for themselves and could lead to the delivery of unnecessary or inappropriate medical services, which are against the resident's goals and wishes.

Inspectors wroteBased on interview and record review, the facility failed to notify the State Long-Term Care Ombudsman (Ombudsman) when six of six sampled residents (Residents 46, 30, 68, 33, 10, 52 and 33) were transferred to the hospital without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for 10 of 18 sampled residents (Resident 33, 54, 282, 21, 48, 9, 70, 71, 76 and 14) when: 1. Resident 33, facility staff failed to address nail care, ensure oxygen (a colorless and odorless gas that people need to breathe) and diet order was administered as specified in the physician's order; and his indwelling catheter care plan was initiated timely; 2. Resident 54 did not receive his restorative nursing assistant treatment (RNA) as specified in the physician's order; 3. Resident 282 did not have a care plan for the use of oxygen; 4. A licensed staff crushed a medication without a physician's order for Resident 21; 5. Resident 48 did not have an initial care plan within 48 hrs from admission; 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fall management and interventions were evaluated and implemented to prevent further falls for four out of 18 sampled residents (Residents 36, 52, 54 and 283) when: 1. For Resident 36, neuro-checks (an evaluation to sensory and motor responses, reflexes to determine if the nervous system is impaired) were incomplete, interdisciplinary team (IDT, staff from different disciplines who work together to plan and provide care) did not discussed falls, OT evaluation was not implemented, no new interventions were implemented after a fall, there was no physician order for the use of soft padded helmet, postural hypotension was not monitored. 2. For Resident 52, medication regimen review (MRR, process of comparing medication), no fall risk assessment, and no evidence an IDT was done after a fall. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident when: 1. Failed to obtain and administer warfarin (Coumadin, a medication that can treat and prevent blood clots) for atrial fibrillation (a-fib, an irregular heartbeat that can cause poor blood flow) for one of 18 sampled residents (Resident 71). 2. An opened refrigerated emergency kit was not replaced timely. The deficient practice resulted in Resident 71 not receiving seven scheduled doses of the medication in October, 14 doses in November and seven doses in December 2021. An e-kit not being replaced in timely manner could put residents needs not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure palatability and safety of cooked foods was maintained when pureed food was runny. These failures had the potential to impact all 19 residents on pureed diets in that it could result in a choking hazard (airway blocked by food), aspiration risk (when food or drink goes into the airway), and decreased palatability which could result in decreased intake and weight loss out of a facility census of 90.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff implemented the infection control practices when: 1. Licensed vocational nurse G (LVN G) brought a medication to Resident 132's bedside and handled the medication bottle with used gloves; 2. There were used gloves near the clean linen in room CC; 3. The curtain in room DD had a whitish discoloration; and 4. Oxygen tubing for Resident 282 was left uncovered . These failures had the potential to result in transmission of infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a standardized assessment and screening tool) was transmitted timely to the Centers for Medicare and Medicaid Services (CMS) system for one resident (Resident 1). This deficient practice had the potential to result in the delay of resident assessments.

Inspectors wroteBased on interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS, an assessment tool) for two of 18 sampled residents (Residents 7 and 78) when the MDS did not reflect the current status of the residents. This failure had the potential to affect inappropriate care planning and intervention.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess the preadmission screening and resident review report (PASRR, an evaluation data requirement to determine whether a resident with mental illness (MI) requires specialized services such as referral to a mental health authority) for two of 18 sampled residents (Residents 71 and 49). This failure had the potential to put the residents at risk for not receiving appropriate care and services.

Inspectors wroteBased on observation and interview, the facility failed to post the daily nurse staffing number of hours ratios (PHPPD) in a prominent place, which was easily visible to all. This failure had potential to affect residents' care due to the lack of nursing working hours information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 18 sampled residents (Residents 10 and 52) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) when: 1. For Resident 10, the facility failed to address the continued use of a PRN (as needed) psychotropic medication in a timely manner. The facility failed to ensure there was a specific duration of use for a PRN psychotropic medication that exceeded 14 days. 2. For Resident 52, Seroquel (medication used to treat mental/mood conditions) did not have specific manifestation and orthostatic hypotension was not monitored. These failures could result in lack of adequate monitoring and had the potential for the residents to receive unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to administer warfarin (Coumadin, a medication that can treat and prevent blood clots) for atrial fibrillation (a-fib an irregular heartbeat that can cause poor blood flow) for one of 18 sampled residents (Resident 71). This deficient practice resulted in Resident 71 not receiving seven scheduled doses of the medication in October, 14 doses in November, seven doses in December 2021 a period of 28 days and put the resident at risk for developing a stroke (damage to the brain from interruption of its blood supply).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications and biologicals were stored appropriately when a medication was left on Resident 34's bedside table and an unopened bottle of Latanoprost was not refrigerated. These failures had the potential to result in the access of medications by unauthorized personnel or residents and use of medications being used past the expiration date.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure staff competency when one of four cooks (Cook 2) did not follow a recipe for the preparation of vegetables which were bland and not palatable. This failure had the potential a decreased intake of food for residents who ate food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five residents (Resident 48) were offered and/or received pneumococcal vaccinations. This failure had the potential to expose residents to pneumococcal infections (caused by common bacteria (streptococcus pneumonia) that can affect different parts of the body).