Yuba City Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision and use of safety devises during transport for one of three sample residents (Resident 1), when Resident 1 was transported to a medical appointment without the use of a lap seat belt. This failure had the potential to result in falls or injuries during transport and caused Resident 1 to feel afraid and unsafe.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was below 5% for 2 of 6 sampled residents (Resident 40 and Resident 4) when: 1. Registered Nurse (RN) B did not administer Resident 4's oral inhalation medication as ordered by prescriber.2. RN G administered Resident 44's medication not in accordance with the standards of practice. As a result, 2 errors were identified out of 26 opportunities for error during the observation of medication administration; the facility medication error was 7.69%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly as specified by the manufacturers when the temperature of a medication refrigerator was out of range below the freezing point. This failure resulted in liquid medications to crystalize and become ineffective.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Medical Director (MD) and the resident was notified of a change in condition for one of three sampled residents (Resident 35) when Licensed Vocational Nurse (LN) J discovered exposed bone and a surgical screw in Resident 35's right lateral ankle wound . This failure had the potential to put Resident 35 at risk of infection and a decrease in quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop comprehensive care plans (a detailed, patient-centered document that summarizes a patient's medical, functional, and psychosocial needs and goals, outlining the interventions and resources needed to achieve them) for two of 18 residents (Resident 33 and 9) who's care plans were reviewed, when: 1. Resident 33 had a deep tissue injury (DTI, localized damage to the skin and tissue caused by pressure on an area for a long time) and there was no care plan developed.2. Resident 9 was noted to be missing teeth on admission and there was no oral/dental care plan developed. These failures had the potential to decrease the physical, psychosocial, and emotional well being of Residents 33 and 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise a comprehensive care plan (a detailed, patient-centered document that summarizes a patient's medical, functional, and psychosocial needs and goals, outlining the interventions and resources needed to achieve them) for one of seven residents (Resident 33) when Resident 33 had a medical equipment change from a cast to a Controlled Ankle Motion boot (CAM boot - a device designed to immobilize and support the ankle joint after an injury or surgery) on the right foot. This failure had the potential to decrease the physical, psychosocial, and emotional wellbeing of Resident 33.

Inspectors wroteBased on interview and record review the facility failed to ensure one of two residents sampled (Resident 58) received services that met professional standards when Resident 58 did not have episodes of diarrhea documented in their medical record to provide a full description of a change of condition for Resident 58. This failure had the potential for Resident 58 to not receive proper care for her diarrhea which could cause decline in physical, mental and psychosocial health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided for two of three residents sampled for skin damage (Resident 49 and 58) when: 1. Resident 58 had developed redness to her bottom and it went unreported by staff and without appropriate treatments for healing. 2. Resident 49 developed a red rash around her mouth and it went unreported by staff and without appropriate treatments for healing. These failures had the potential for Resident 58 and 49's physical, mental, and psychosocial needs to go unmet.

Inspectors wroteBased on interview and record review the facility failed to ensure annual performance evaluations for three out of four Certified Nursing Assistants (CNA C, E, and F) were completed every 12 months. This had the potential for direct care staff not to provide quality of care and meet the needs of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain its infection prevention control program when: 1. One of one resident (Resident 58) sampled for Transmission Based Precautions (TBP) was suspected to have Clostridium Difficile (c-diff, a bacterium [germ], transmissible infection [easily spreads to another person], that causes an infection of the colon, the longest part of the large intestine. Symptoms can range from diarrhea to life-threatening damage to the colon) and no isolation precautions were initiated as per policy to prevent the spread of disease. This failure had the potential to spread c-diff to other residents and staff and cause severe illness and decline in health status. 2. [...]

Inspectors wroteBased on Interview and Record Review the facility failed to report a crime or abuse incident for 1 of 3 residents (Resident 1) when Resident 2 ' s Family Member (FM) exposed himself to Resident 1 while in Resident 1 and Resident 2 ' s shared room. This failure to report to proper authorities placed all residents at risk for allegations of abuse to go unreported.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision based on individual resident needs, for three out of three sampled residents (Residents 34, 50, and 28) when: 1. Facility staff was aware Resident 34 wandered (roamed from place to place) in and out of other resident rooms. 2. Facility staff was aware Resident 50 wandered in and out of other resident rooms. 3. Facility staff was aware that Resident 28 demonstrated daily episodes of increased agitation and volatility exhibited by yelling, cursing, and throwing items. This failure had the potential to impact resident safety, privacy, dignity, and placed residents at an increased risk for resident-to-resident altercations.

Inspectors wroteBased on observation, interview and record review the facility failed to assure that there was sufficient, qualified nursing staff available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promotes each resident's rights, physical, mental and psychosocial well-being for 11 of 30 residents (Resident 215, 28, 57, 45, 5, and 365), and Confidential Interview Residents), when call lights were observed and reported to go unanswered for extended periods of time resulting in: 1. Residents being left in soiled briefs with bowel movement and/ or urine. 2. Residents being left on the toilet for extended periods of time. 3. Residents left waiting for assistance in bed for a variety of reasons, including for generalized needs, or attempting to receive assistance to go to the to toilet. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete Medication Regimen Reviews (MRR) were performed for medication irregularities, appropriate indication (reason for use), and/or unnecessary psychotropic (affecting mental state) medications for two of four sampled residents (Residents 50 and 25) when: 1A. The indication for Seroquel (medication affecting mental processing and behaviors) use of mood disorder as evidenced by (AEB) striking during care was determined appropriate for Resident 50 on two MRRs by Consultant Pharmacist (CPH), though medication necessity and effectiveness had not been evaluated (50 days after admission) by the Psychotropic Interdisciplinary Team (IDT - group of professional healthcare providers including physician(s), nurses, pharmacists who meet to determine appropriateness of resident medication treatment plans). 1B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate did not exceed 5 percent for two of six sampled residents (Residents 25 and 216) when: 1. For Resident 25, Licensed Nurse D (LN D) administered one oxybutynin extended-release (ER) 5 milligrams (mg - a unit of measure) tablet rather than the ordered oxybutynin chloride 5 mg, an immediate-release (IR) tablet, to treat overactive bladder. 2. For Resident 216, LN D did not administer scheduled or as-needed pain medications when Resident 216 stated his pain was 10 on a scale of 1 to 10 (1 being the lowest pain, 10 being the highest). These failures resulted in two medication errors identified out of 29 opportunities, resulting in a medication error rate of 6.9 percent, with the potential for adverse health consequences from medication toxicity effect and unaddressed pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications and medication supplies were stored and labeled in accordance with currently accepted professional principles when: 1. A discontinued medication was not removed and discarded from an active medication drawer in Medication Cart A (MC A), 2. Six multi-dose tubes of noncontrolled medicated creams (prescription medications with less risk of addiction and abuse) were in a facility supply basket in Treatment Cart 1 (TC 1) without patient-specific labeling, 3. A used oral medication syringe was affixed with a rubber band to a bottle of liquid Keppra (anti-seizure medication) for reuse and was stored in a drawer of TC 1, 4. A bottle of glucose test strips was open and undated in MC A, 5. Eight loose pills were found in drawers and on the bottom of MC A, 6. [...]

Inspectors wroteBased on observation, interview, and record review, the food and nutrition services department failed to provide food that was palatable (good temperature, tasted good) when residents from a confidential interview and 11 out of 22 sampled residents (Residents 5, 16, 28, 30, 37, 38, 43, 45, 57, 59, and 215) stated the food did not taste good and was cold. This failure had the potential for unintended weight loss.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to local, state, and federal agencies, including the California Department of Public Health (CDPH), when Certified Nurse Assistant (CNA) E stated, CNA E observed Resident 48 shaking a fist and making verbal threats to harm Resident 50. This failure placed all residents at risk for allegations of abuse to go unreported.

Inspectors wroteBased on interview and record review, the facility failed to revise care plans (a document that described health conditions, the level of care the resident required, and how that care would be provided) for two out of two sampled residents (Residents 34 and 50) when: 1. Resident 34's care plan was not revised to include wandering behaviors (roaming from place to place). 2. Resident 50's care plan was not revised to include a change in wandering behaviors. This failure had the potential to cause a decline in physical, mental, and psychosocial well-being and placed Residents 34 and 50 at risk for harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents' pain was managed for 1 of 30 residents (Resident 216) sampled for pain management when Resident 216 complained of having pain in their ribs and low back while making facial expressions and exhibiting body movements that demonstrate signs related to the experience of pain. Resident 216 was unable to verbalize a specific number to represent the level of pain being experienced per the Pain Scale (standardized numeric scale to identify an individual's pain level. Scale rates pain from 0-10; 0 = no pain to 10 = most severe pain). Thus, Resident 216 did not receive pain medication per the medical doctor's (MD) orders. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review indications for continued use or attempt Gradual Dose Reduction (GDR - tapering of a dose to determine if symptoms, conditions, or risks can be managed by lowering or discontinuing medication) for 50 days for one of one sampled resident (Resident 50) receiving four psychotropic medications: (1) lorazepam (anti-anxiety medication that slows brain activity for relaxation), (2) Seroquel (anti-psychotic medication, indicated for psychosis, that improves mood, thoughts, and behaviors), (3) trazodone (anti-depressant medication), and (4) sertraline (anti-depressant - increases serotonin, a mood-enhancing chemical, in the brain). Psychotropic medications affect brain activities associated with mental processes and behaviors and include anti-psychotic, anti-depressant, and anti-anxiety medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident food preferences (food that was liked or disliked) and did not serve accurate portions when: 1. One out of five sampled residents (Resident 45) stated, the facility served food that Resident 45 did not like. 2. The facility did not provide the correct portion size of fish to residents during lunch on 8/29/24. These failures had the potential for unintended weight gain or unintended weight loss which could negatively impact resident health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in good repair when the pots and fry pans had a black build up on the outside, the inside protective layer of the fry pans was missing (caused metal to be exposed), and one fry pan had a thick, black buildup of material on the inside where food was cooked. This failure had the potential to contaminate food and cause a decline in resident health.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to ensure that a resident's needs and choices for personal hygiene (dressing, grooming, and oral care) were met for three of three sampled residents (Resident 1, 2, and 3). This failure had the potential to adversely affect the resident's psychosocial well-being by not receiving hygiene and feeling dirty.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation to meet the resident's need and preferences for one of three sampled residents (Resident 3), when a shower schedule was not provided and a shower was offered before bedtime, which was too late according to the resident's preferences. This failure resulted in Resident 3 missing her shower and feeling disappointed.

Inspectors wroteBased on interview and record review, the facility failed to ensure that their Quality Assurance and Performance Improvement plan (QAPI) committee identified and developed action plans to correct the deficient practices in the delivery of quality nursing care, prior to the survey findings. These failures resulted in a substandard quality of nursing care and actual harm to one resident (Resident 99). These failures had the potential to further affect the health, safety and well-being of all of the residents in the facility and leave them vulnerable to poor quality nursing care.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff completed timely a comprehensive quarterly assessment for one of 12 residents (Resident 99). This failure resulted in no plan of care for Resident 99's non-verbal pain to go unrecognized and untreated.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and/or revise the care plans for three of three sampled residents (Resident 346, 29, and 99) when: 1. Resident 346 had no care plan developed for a pressure injury (bed sore) and for psychotropic drug use (drugs that alter mood and behavior). This resulted in Resident 346 having no plan for the treatment of her pressure injury and no goals for using psychotropic drugs. 2. Resident 29's care plan was not revised with specific interventions for irrigating a suprapubic catheter (a tube that goes directly into the bladder from the abdomen to drain urine when the kidneys no longer work). This resulted in Resident 29 receiving unsterile catheter care when it should have been sterile. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement it's care plan for one of 37 residents (Resident 10) according to policy on falls. This resulted in the resident experiencing a fall, and created the potential for further falls, injury, illness and death.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete pain management assessment, develop and implemented a comprehensive person-centered plan for non verbal pain for one of four residents (Resident 99). As a result, Resident 99 suffered unnecessary severe pain from a blot clot that required surgical intervention for a right above knee amputation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that nursing staff possessed the competencies and skill set necessary to provide nursing care for 3 of 12 sampled residents (Residents 20, 29 and 99) when: 1. Nursing staff did not have sufficient knowledge to appropriately assess and manage a PICC line for Resident 20 when a Peripherally Inserted Central Catheter (PICC) (a medical device that was placed into a large vein to allow access to the bloodstream) clotted two times, the tip of the PICC was not in a favorable position for IV therapy to be administered, two doses of antibiotic therapy were missed, the PICC line cap was missing, and physcian orders for catheter flush was incorrect; 2. Nursing staff did not have sufficient knowledge of sterile bladder irrigation technique for Resident 29; and 3. [...]

Inspectors wroteBased on Dietetic Services observation, Registered Dietitian and Dietary Services Supervisor interview, and departmental document review, the facility failed: 1) To ensure the Dietary Services Supervisor (DSS) completed the required 6 hours of State regulatory training prior to assuming the leadership role. 2) To ensure the Registered Dietitian and/or Dietary Services Supervisor provided comprehensive oversight and staff guidance when: 2A) Staff did not perform food safety procedures such as food thawing, labeling and dating, food temperature monitoring, according to professional standards of practice. 2B) There was not an effective system in place to ensure cooks prepared adequate food to meet resident nutrition needs and preferences. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure staff were competent to perform food preparation and food safety processes according to professional standards when: 1. Two staff did not monitor food cooking and serving temperatures consistently to ensure food safety and palatability. 2. Two staff did not follow menu spreadsheets or prepare and serve adequate amounts of food to meet menu requirements and resident needs. 3. Staff did not correctly label and date food. 4. Staff did not use safe food thawing processes. Failure to ensure staff are competent to complete essential job and food safety functions increases the potential for foodborne illness to occur and also increases the risk that meals provided will not meet the nutritional needs and preferences of residents. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop a menu in accordance with physicians' orders, cultural/ethnic needs and/or resident preference for 3 out of 3 residents (Residents 27, 39 and 195) with a vegetarian diet order. This failure increased the risk that meals provided to vegetarian residents would not meet their nutritional needs and had the potential to negatively impact resident's meal satisfaction, meal intake and overall health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was stored, prepared and distributed in accordance with professional food safety standards when: 1) Food was not thawed, labeled, dated, or discarded appropriately. 2) Cooked food temperatures were not consistently monitored or documented. 3) Food service equipment was not clean, and manufacturer's instructions were not followed when sanitizing fixed equipment. 4) Staff personal food and personal possessions were in use in food preparation areas. These practices have the potential to result in foodborne illness for residents consuming food from the facility food services.

Inspectors wroteBased on observation, interview, and record review the facility failed to have an effective process in place to ensure one of three sampled residents (Resident 39) and all residents that had food items brought into the facility, were able to receive safe and sanitary food brought in by family or others, and receive assistance with reheating and preparation of food when: 1. Food was not allowed if it did not comply with the resident's diet order. 2. Hot food brought in by family or others was discarded if not eaten within an hour. 3. Nursing would not reheat food for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their infection prevention policies and procedures for 3 of 7 sampled residents when: 1. They performed bladder irrigations (using a large syringe with a solution to flush out sediment and matter that may plug the drainage of the catheter) on the resident without using a sterile technique (creating a sterile (germ free) field for the procedure) or sterile supplies (sterile gloves and sterile bladder irrigation kits) and; 2. Nursing staff provided incontinent care (cleansing after emptying the bowel and bladder) without changing gloves or sanitizing their hands before continuing with other care and; 3. Oxygen tubing was observed on the floor beneath the oxygen concentrator (a machine powered by electricity that separates oxygen from the air and delivers it to the resident via the tubing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure that the call system was within reach for one of twelve sampled residents (Resident 9). This failure had the potential to put Resident 9 at risk for not getting help when needed which could have threatened their well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify a physician of a change of condition for one of 12 residents (Resident 99) when she had severe pain caused by decreased blood circulation in her right leg. This resulted in Resident 99 having continued severe pain due to a blood clot that required surgical intervention of removing her right leg above the knee.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to maintain good grooming and hygiene for one of twelve sampled residents (Resident 9) when the resident's fingernails were long and dirty. This failure had the potential to cause breaks in Resident 9's skin and to spread germs which could have caused infections.

Inspectors wroteBased on interview and record review the facility failed to ensure nursing staff developed and implemented a resident plan of care for two of four residents (Resident 99 and ) when: 1. Resident 99's change of condition for skin and pain were not identifed through the nursing assessments. This failure resulted in Resident 99 to have severe pain and required surgical intervention for a right above knee amputation. 2. The nursing staff failed to provide appropriate care and services according to facility's policy and professional standards of care to assess and maintain Resident 20's Peripherally Inserted Central Catheter (PICC) (A soft, long catheter that is inserted into a vein in the arm and the tip is positioned in a large vein near the heart). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one of three residents (Resident 10) from accidental hazards when it did not follow its policy for resident safety. This resulted in a resident's fall and the potential for further falls, injury, illness and death. Refer to tag F658.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 3 of 5 sampled Residents were free from unnecessary psychotropic drug use (drugs that are used to control or alter mood and behavior such as antipsychotic, antianxiety, antidepressant and hypnotic medications), when they either monitored the wrong side effect for the drug, had no monitor in place, or had not monitored a target symptom (behavior). This lack of correct monitoring had the potential to negatively impact the Residents quality of life by subjecting them to unrecognized potentially life-threatening and uncomfortable adverse medication side effects and impair their mental, physical and emotional well-being. (Residents 29, 38 and 346).