BANCROFT HEALTHCARE CENTER
For profit - Corporation
39 Beds
Independent
Data: November 2025
Trust Grade
65/100
#290 of 1155 in CA
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bancroft Healthcare Center has a Trust Grade of C+, indicating it's slightly above average but not particularly outstanding. It ranks #290 out of 1,155 facilities in California, placing it in the top half of all nursing homes in the state, and at #27 out of 69 in Alameda County, meaning there are only a few better options nearby. The facility is improving, having reduced its issues from nine in 2024 to just one in 2025, though it currently has a staffing rating of 1 out of 5 stars, which is poor, with a turnover rate of 41%, similar to the state average. Notably, the center has no fines on record, suggesting compliance with regulations, but it has less RN coverage than 98% of other California facilities, which may impact care quality. Specific incidents of concern include a serious issue where a resident in hospice care did not receive appropriate management of withdrawal symptoms from medication, causing unnecessary pain and distress, and the failure to obtain informed consent for bed side rails for all residents, which could lead to avoidable injuries. Overall, while there are significant strengths in compliance and trend improvement, the staffing situation and specific care incidents raise concerns about the quality of care provided.
- Trust Score
- C+
- In California
- #290/1155
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 9 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 30 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 25%
Needs review
9 → 1 violations
★★★★☆
4.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 1 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 41%
Near California avg (46%)
Typical for the industry
The Ugly 30 deficiencies on record
1 actual harm
Aug 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, licensed nursing staff did not provide care according to professional standards for 1 of 3...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, licensed nursing staff did not provide care according to professional standards for 1 of 3 sampled residents (Resident 1). Resident 1 had been prescribed oxycodone (narcotic) since 2024 and was in hospice (end-of-life care for a terminal illness.) When Resident 1 could no longer swallow her pills, facility staff did not have a plan in place to address withdrawal symptoms from the oxycodone.This resulted in Resident 1 experiencing unnecessary pain, agitation and distress.During a review of Resident 1's clinical document titled admission Record, the admission record indicated, the facility admitted Resident 1 on 12/14/2023 with multiple medical diagnoses including multiple fractures, cerebral infarction (stroke) and chronic pain syndrome. During a review of Resident 1's clinical document titled Physician's Order dated 4/7/2025, the document indicated, Resident 1 was admitted into hospice care with terminal diagnosis of Dysphagia (inability to swallow) due to cerebrovascular(stroke). During a review of Resident 1's clinical document titled MDS 3.0 Nursing Home Quarterly (NQ) Version 1.19.1 (Resident Assessment) dated 3/26/2025, the MDS indicated, Resident 1 was alert, could repeat the number of words presented to her and could identify the year and month. During a review of Resident 1's clinical document titled Order Summary Report dated 4/1/2025, the document indicated, staff were to administer Baclofen (muscle relaxant) 3 times per day, Lyrica (medication for nerve pain) 3 times per day and oxycodone 10 milligrams 4 times a day for pain management for Resident 1. During a review of Resident 1's clinical document titled Medication Administration Record (MAR), dated March 2025, the MAR indicated Resident 1 had received the medications Baclofen, Lyrica and Oxycodone every day in March and into April of 2025. Further review of the MAR showed the start date for the oxycodone was 1/2/2024. During a review of Resident 1's MAR dated April 2025, the MAR indicated Resident 1 was able to take the Baclofen and Lyrica the morning of 4/12/2025 but refused subsequent dosages. Further review of the MAR showed the last dose of oxycodone was administered on 4/11/2025 at 5 p.m. During a review of Resident 1's clinical document titled Progress Notes *NEW*, the progress notes indicated, on 4/12/2025 at 2:33 a.m., Resident 1 was Resting comfortably but arousable. No complaints of pain or discomfort. Review of the note dated 4/12/2025 at 11:07 p.m. showed Resident 1 Appeared to be (having) multiple (episodes of) confusions and episodes of screaming during shift. Resident 1 had Refused most of the medications, Morphine and Ativan given. (30 hours and 7 minutes since the last administered dose of oxycodone) (Morphine: pain medication) (Ativan: anti-anxiety medication) During a review of Resident 1's clinical document titled Pulse Summary indicated at 9:22 p.m. on 4/12/2025, Resident 1's pulse was elevated at 98. Her baseline range for April 2025 showed a pulse in the 60's and 70's. (normal range is 60-100) Review of the document O2 Sats Summary showed Resident 1's oxygen saturation at 9:22 p.m. on 4/12/2025 was 52% (amount of oxygen in the blood: normal range 95-100%) During further review of Resident 1 s progress notes showed the following: 4/13/2025 at 10:43 a.m. - Resident is having frequent episodes of restlessness, agitation and screaming. Resident is clearly in severe discomfort despite administering morphine and Ativan. 4/13/2025 at 1:50 p.m. - Resident is still in severe discomfort and distress. 4/13/2025 at 9:55 p.m. - Resident is in declining condition. Resident appears to be (having) episodes of confusion and screaming. There was nothing in the clinical record which showed the doctor had been notified regarding the screaming and abrupt discontinuation of the oxycodone. During a record review of the document Hospice admission Plan of Care dated 4/7/2025 indicated no plan had been put into place to address stopping the oxycodone and potential for withdrawal. During an interview on 7/16/2025 at 4:44 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN1 confirmed, on 4/12/2025 Resident 1 had refused most of her medications and was agitated. LVN 1 stated she had not notified the doctor regarding the screaming and abrupt stoppage of the oxycodone but stated she should have because Something was wrong with the medication. During an interview on 7/25/2025 at 2:06 p.m., with Director of Nursing (DON), DON confirmed there was nothing in the clinical record which showed the doctor had been notified regarding the abrupt stopping of the oxycodone and continued screaming. The DON also stated, Stopping Oxycodone suddenly can cause withdrawal symptoms and there had been no back-up plan or updated plan of care in place when Resident 1 could no longer swallow the oxycodone. During an interview on 7/28/2025 at 1:57 p.m., with DON, DON stated Resident 1 had not received the oxycodone on 4/12/2025 because she was getting lethargic and Could not swallow it. The DON stated signs of withdrawal included being Anxious, can't relax, irritable, restless, mood changes. During a review of Resident 1's clinical document titled Progress Notes *NEW* dated 4/14/2025 timestamped at 7:40 a.m., the progress note indicated Resident 1 was Sleeping with daughter and hospice nurse at bedside, occasional moaning noted, routine morphine given and Lorazepam (anti-anxiety medication)) with good result. (41 hours and 46 minutes since she was last described as Resting comfortably on 4/12/2025 at 2:33 a.m.) Record review of Resident 1's clinical document titled Progress Notes *NEW* dated 4/14/2025 showed Resident 1 passed away on 4/14/25 at 1:40 p.m. During an interview on 8/11/2025 at 11:05 a.m., with facility's consulting pharmacist (CP), CP stated You never want to stop oxycodone because of withdrawal. The CP stated best practice is to use something similar to alcohol withdrawal and typically there is a protocol that is used. The CP stated one option would have been for staff to slowly decrease the dosage of the oxycodone and consulted with a pain management group Especially as she developed swallowing issues. The facility's physician did not respond to a request for an interview. During a review of the facility's policy and procedure (P and P) titled HO: The Plan of Care dated 1/5/2023, the P and P indicated This plan will focus on identified problems, goals, and interventions and include all services necessary for the palliation and management of the terminal illness and related conditions. (HO: hospice) During a review of the facility's undated policy and procedure titled Narcotic Medication Monitoring indicated, if pain has not been adequately controlled, the Multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Record review of a National Institute of Health article indicated Abrupt cessation of short-acting opioids (e.g. Heroin, hydrocodone, and oxycodone) is associated with severe OWS (opioid withdrawal symptoms) that typically begin within 12 hours after a missed dose, peak at 36-72 hours, and gradually taper off over the following 4-7 days. Opioid withdrawal symptoms: aches/pain, muscle spasms/twitching/tension, tremor, abdominal cramps, nausea/spasms/twitching/tension, tremor, abdominal cramps, nausea/vomiting/diarrhea, anxiety/restlessness, irritability. [Review article: Effective management of opioid withdrawal symptoms: A gateway to opioid dependence treatment. NIH: National Library of Medicine: January 31, 2019: pmc.ncbi.[NAME].nih.gov/articles/PMC5590307]
Oct 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS-Resident Assessment and Care Screening tool used to guide care), accurately reflect the assessment status for two (Resident 4 and 12) of fourteen sampled residents when
1. Resident 4's MDS section G did not reflect limitation in range of motion to upper and lower extremities (hip, knee, ankle, foot), and
2. Resident 12's MDS section K did not reflect a significant weight loss.
These failure had the potential for residents to not receive appropriate care and services.
Findings:
1. During a review Resident 4's admission Record (AR), AR indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis of knee (the wearing down of the protective tissue at the ends of bones cartilage occurs gradually and worsens over time).
During a review of Resident 4's care plan review date 9/11/24, the care plan indicated Resident 4 had limited physical mobility to upper and lower extremities related to weakness, osteoarthritis of knee and total care.
During a review of Resident 4's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 5/24/24, Section G indicated Resident 4 had no limitation in range of motion to upper and lower extremities.
During a concurrent observation and interview on 10/9/24 at 12:15 p.m. with the Director of Nursing (DON), and Registered Nurse/MDS coordinator (RN 1), in Resident 4's room, Resident 4 laid in bed both feet elevated on pillow, awake and verbally responsive. Resident 4 stated her right foot dragged to the side when she laid in bed and had to call for assistance to pull her foot back to position. Resident 4 stated she needed exercise therapy.
During a concurrent interview and record review on 10/9/24 at 12:25 p.m. with RN 1, Resident 4's MDS section G dated 5/4/24 was reviewed. MDS section G indicated Resident 4 had no limitation in range of motion to lower extremities. RN 1 stated Resident 4's MDS section G limitation in range of motion was not coded accurately.
2. During a review Resident 12's admission Record (AR), AR indicated Resident 12 was admitted to the facility on [DATE] with diagnoses that included Dysphagia (difficulty swallowing).
During a review of Resident 12's Annual Minimum Data Set (MDS), Resident Assessment and Care Screening tool used to guide care, dated 7/29/24, Section K weight loss indicated, Resident 12 had no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months.
During a concurrent interview and record review on 10/09/24 at 1:26 p.m. with the Registered Dietician (RD), Resident 12's Nutrition/Dietary Note, dated 7/18/2024 was reviewed. The Nutrition note indicated, Resident 12 had a significant 9.3-pound weight loss in 90 days (5.8%) in 90 days, significant 17.4-pound weight loss in 180 days (10.3%) in 180 days (from dates December 2023-June 2024). RD stated Resident 12 had significant weight loss in the last six months.
During a concurrent interview and record review on 10/10/24 at 9:46 a.m. with the Dietary Manager (DM), Resident 12's weight record was reviewed. Resident 12's weight record indicated the following: 6/4/24 = 152.5 pounds (#), 7/2/24 = 143#, 8/2/24 = 147#, 9/3/24 = 138# and 10/1/24 = 128#. DM stated he was responsible for entering data for section K weight loss. DM stated Resident 12 had significant weight loss. DM stated MDS section K was not coded accurately. DM stated he did not calculate the weight variance correctly.
During a review of the facility's policy and procedure (P&P) titled, MDS-Comprehensive Assessments undated, the P&P indicated, Comprehensive assessment are conducted to assist in developing person-centered care plans. A significant error is an error in an assessment where the resident's overall clinical status is not accurately represented (i.e., miscoded) on the erroneous assessment and/or results in an inappropriate plan of care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure one (Resident 32) sampled resident on tube feeding (Tube feeding refers to the delivery of nutrients through a feeding ...
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Based on observation, interview and record review, the facility failed to ensure one (Resident 32) sampled resident on tube feeding (Tube feeding refers to the delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum. It is also referred to as an enteral feeding.) maintained acceptable nutritional status and body weight range when Resident 32's unplanned weight loss was not reevaluated with appropriate interventions by the Registered Dietician (RD), and the facility did not notify the physician and responsible party of Resident's 32 unplanned weight loss.
This failure had the potential to result in Resident 32's dehydration and unplanned weight loss.
Findings:
During a review of Resident 32's admission Minimum Data Set (MDS - Resident assessment and care guide tool), dated 7/29/24, the MDS indicated Resident 32's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 00 and indicated impaired mental status. The MDS indicated Resident 32 received nutrition through abdominal feeding tube Resident 32's diagnoses included stroke and Non-Alzheimer's Dementia ((a group of diseases characterized by progressive deficits in behavior, executive function, or language).
During a review of Resident 32's Order Summary Report, dated 7/3/24, the order indicated, physician prescribed Resident 32 to receive tube feeding diet, tube feeding texture and NPO (nothing by mouth).
Further review of Resident 32's order summary report dated 7/6/24 indicated physician prescribed Jevity (calorically dense, fiber-fortified therapeutic nutrition and liquid food) 1.2 kcal, 45 ml/hr. for 20 hours per day via continuous drip 4 hours off per day. Provide total volume of 900 ml, 1080 kcals, 50 grams protein and 725 ml free water.
During a review of Resident 32's weight summary report, dated 7/3/24 through 10/7/24, the report indicated:
7/3/24 Resident 32 weighed 94 pounds (#)
7/9/24 Resident 32 weighed 92.5#
7/16/24 Resident 32 weighed 84#
7/23/24 Resident 32 weighed 84#.
7/30/24 Resident 32 weighed 83.5#
8/2/24 Resident 32 weighed 83.1#
9/6/24 Resident 32 weighed 81#
10/7/24 Resident 32 weighed 82#
Further review of Resident 32's weight summary report dated 7/3/24 through 10/7/24, indicated: Resident 32 had weight loss of 7.5% or 10.5 # change comparison weight on 7/9/24 and 10% change weight comparison 12# weight loss in 3 months.
During a concurrent interview and record review on 10/9/24 at 1:41 p.m. with Registered Dietician (RD), Resident 32's weight summary record dated 7/3/24 through 10/7/24 was reviewed. The weight report indicated Resident 32 had a significant weight loss of 10.5# comparison weight 7/9/24 and 12# weight loss in 3 months. RD stated Resident 32 was on tube feeding and had nothing by mouth. RD stated Resident 32 weight loss was unplanned weight loss. RD said she did not notice that Resident 32 had a weight loss. RD stated she had not reevaluated Resident 32 tube feeding intake. RD stated she was not informed of Resident 32's weight changes.
During a concurrent interview and record review on 10/9/24 at 1:20 p.m. with Licensed Vocational Nurse (LVN 3), Resident 32's weight summary record dated 7/3/24 through 10/7/24 was reviewed. LVN 3 stated Resident 32 had significant weight loss. LVN 3 stated he did not notify the physician and responsible party of Resident 32's significant weight loss. LVN stated he believed the Director Of Nursing (DON) will follow up on weight loss. LVN 3 stated was supposed to notify the family and doctor.
During a review of Resident 32's potential nutritional care plan, Resident 32's nutrition risk care plan did not address significant weight loss with appropriate interventions.
During a concurrent interview and record review on 10/9/24 at 11:05 a.m. with DON, Resident 32's Progress Notes dated 7/3/24 to 10/3/24 was reviewed. DON stated there was no documentation that Resident 32's responsible party and physician were notified of significant weight loss. DON stated facility's protocol was for licensed nurses to notify family and physician. DON stated its important to notify physician to reevaluate residents' nutritional status and for residents to get adequate and proper nutrition. DON stated residents' family should be notified of weight loss because responsible parties have the right to know and may have input to support care. DON stated RD had the access to electronic record to review residents weight variances.
During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention undated, the P&P indicated, The Dietician will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change have been met.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (Resident 18) sampled resident was free fro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one (Resident 18) sampled resident was free from unnecessary drugs when Resident 18 with diagnosis of Alzheimer Dementia was administered Seroquel (Antipsychotic medication are drugs used to treat schizophrenia and bipolar serious mental health conditions, capable of affecting the mind, emotions, and behavior) medication without adequate clinical indication for continued usage.
This failure had the potential for Resident 18 to receive unnecessary medications and had the potential for the Resident 18 to suffer adverse medication side effects.
Findings:
During a review of Resident 18's Significant change in status-Minimum Data Set (MDS, Resident Assessment and care guide tool), dated 5/17/24, indicated Resident 18's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.). Resident 18's score was 01 and indicated poor cognition. Resident 18 had no physical or verbal behavioral symptoms directed towards others e.g., hitting, kicking, pushing, scratching, grabbing or screaming at others. MDS indicated Resident 18 did not exhibit behavior of rejection of care. Resident 18's diagnoses included Alzheimer's Disease (a group of diseases characterized by progressive deficits in behavior, executive function or language).
During a review of Resident 1's Order Summary Report dated 3/2/24, the order indicated the physician prescribed Resident 18, Seroquel oral tablet 25 mg give one tablet by mouth two times a day related to unspecified dementia without behavioral disturbance, psychotic disturbances manifested by kicking/hitting to others.
During a review of the Medication Administration Record (MAR), dated 9/1/24 to 9/31/24 indicated Resident 18 was administered Seroquel 25 mg one tablet by mouth two times a day related to unspecified dementia manifested by kicking/hitting others.
During an observation on 10/7/24 at 10:08 a.m. Resident 18 sat up in bed awake, alert and non-English speaking. Resident 18 had a laptop on her and listened to non-English program.
During an interview on 10/8/24 at 2:35 p.m. Social Service Director (SSD) stated Resident 18 had no behavioral symptoms of hitting or kicking. SSD stated Resident 18 attended activities every day and had supportive family that visited daily.
During an interview on 10/8/24 at 2:40 p.m. with Certified Nursing Assistant (CNA 4), CNA 4 stated Resident 18 had no behavior of hitting or kicking during care. CNA 4 stated Resident 18 attended activities and her family visited every day
During an interview on 10/09/24 at 9:16 a.m. with the Director of Nursing (DON), the DON stated she was informed by CNAs that Resident 18's behavior symptoms included kicking and hitting care giver during evening time. The DON stated Resident 18 did not have behavior all the time but it depended on from day to day.
During a review of Resident 18's Preadmission Screening and Resident Review (PASRR) screening dated 1/25/24, the PASRR (Preadmission Screening and Resident Review is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings.) indicated Resident 18 had no Serious Mental illness.
According to the Seroquel manufacturer, elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Seroquel not approved for use in psychotic conditions related to dementia. Although causes of death varied, most of the deaths appeared to be related to cardiovascular (e.g. heart failure, sudden death).
[Reference: https://www.[NAME].com/seroquel].
During a review of facility's policy and procedure (P&P) titled, Antipsychotic Medication Management undated, the P&P indicated Residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will not be used if the only symptoms are one or more of the following; wandering, restlessness, impaired memory, inattention or indifference to surroundings, nervousness, uncooperativeness .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when:
1. ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage and labeling when:
1. One box of expired blood glucose test strips (small, disposable plastic strips that measure blood sugar levels) for Resident 137 was stored in the medication room,
2. A bottle of liquid Lorazepam (medication used to treat anxiety) which belonged to a deceased resident was stored in the refrigerator in the medication room, and
3. A bottle of expired Senna (laxative) tablets was stored in the medication cart 2.
These failed practices could contribute to unsafe medication use in the facility.
Findings:
1. During a concurrent observation and interview on 10/7/24 at 10:20 a.m. with the Director of Nursing (DON), one box of expired blood glucose test strips with an expiration date of 2/25/21 for Resident 137 was found stored in the medication storage room. DON stated the expired blood glucose strips should have been disposed.
Review of Resident 137's admission Record (AR) dated 10/10/24, indicated Resident 137 was admitted on [DATE] with diagnoses that included Diabetes Mellitus (a disease of inadequate control of blood levels of sugar). The AR indicated Resident 137 was discharged on 3/19/20.
Review of Resident 137's Physician's Order indicated an order with a start date of 2/28/20 of Sliding Scale Insulin before meals and bedtime (Insulin is a hormone that regulates blood sugar levels in the body. Sliding scale meant the insulin dose the resident would receive before the resident's meals and bedtime was based in the blood sugar level result).
2. During a concurrent observation and interview on 10/7/24 at 10:25 a.m. with the DON, one bottle of liquid Lorazepam that belonged to Resident 15 was found stored in medication room refrigerator. DON stated that the resident was already deceased . DON also stated the Lorazepam should have been disposed.
Review of Resident 15's AR dated 10/10/24 indicated Resident 15 was admitted to the facility on [DATE]. The AR also indicated that Resident 15 expired on 9/27/24.
Review of Resident 15's Physician's order indicated an order with a start date of 8/15/24, of Lorazepam 2mg./ml., give 0.5 ml. by mouth every 12 hours as needed (mg. is milligrams and ml. is milliliters, mg. and ml. are forms of measurement).
3. During a concurrent observation on 10/7/24 at 3:00 p.m. with the DON present, the medication cart 2 had a bottle of the medication Senna (laxative) tablets with an expiration date of 6/2023.
During an interview on 10/10/24, at 11:25 a.m., with the DON, the DON stated the expired medications should have been disposed because the residents might suffer adverse side effects if they received the expired medications.
During a review of the facility's policy and procedure (P&P) titled Medication Storage, Storage of Medication dated 2007, the P&P indicated, .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock disposed of according to procedures for medical disposal .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure one (Resident 7) sampled resident received and consumed foods in the appropriate form and/or the appropriate nutritive ...
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Based on observation, interview and record review, the facility failed to ensure one (Resident 7) sampled resident received and consumed foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician when Certified Nursing Assistant (CNA 5) served Resident 7 a meal tray of pureed diet that belonged to Resident 13.
This failure had the potential to cause residents to receive and consume foods that are not in the appropriate texture and nutrient content to support the resident's needs cause choking or food allergy.
Findings:
During a review of Resident 7's Significant change in status-Minimum Data Set (MDS - Resident assessment and care guide tool), dated 12/25/23, the MDS indicated Resident 7's was on a mechanically altered diet. Resident 7 needed partial to moderate assistance with eating. The MDS indicated Resident 7's diagnoses included Aphasia (a language disorder that affects a person's ability to communicate) and stroke.
During an observation on 10/8/24 at 12:10 p.m. in the Dining Room (DR) there were six residents eating in the dining room. Observed Certified Nursing Assistants (CNAs) serving meal trays to residents. Residents started eating, light music played with activity staff present in the dining room. Resident 7 was served a tray of puree food by CNA 3. Resident 7 started to eat from the plate.
During an observation on 10/8/24 at 12:25 p.m., CNA 2 came into the dining room with a meal tray, presented a meal tray to Resident 7, swapped his meal and left.
During an interview on 10/8/24 at 12:26 p.m. with CNA 2, CNA 2 stated she swapped Resident 7's meal tray because Resident 7 was served Resident 13's meal tray. CNA 2 stated it was very important to check that the right resident received the correct meal tray for residents' safety.
During a review of Resident 7's physician order dated 3/14/24, physician ordered Resident 7 to receive regular diet mechanical soft texture, thin consistency for increase fiber.
During a review of Resident 13's physician order dated 6/9/21, the physician ordered Resident 13 to receive fortified diet pureed texture, honey consistency, related to dysphagia, oropharyngeal large portion.
During an interview on 10/8/24 at 12:13 p.m. with CNA 3, CNA 3 stated it was important to check names to make sure the right resident received the right diet order. CNA 3 stated it was also important because some residents were diabetic or allergic to some food items.
During an interview on 10/8/24 at 12:53 p.m. with the DON, the DON stated the facility's protocol was that licensed nurses were responsible to check meal trays before CNAs served residents. The DON stated CNAs should also check the names on the tray. The DON stated residents should receive the right diet as ordered to prevent choking or allergy.
During a review of the facility's policy and procedure (P&P) titled, Assistance with Meals undated, the P&P indicated, Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Facility staff will serve resident trays accurately and will help residents who require assistance with eating.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show document...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents' medical records were updated to show documentation that advanced directives (written statement of a person's wishes regarding the medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor), were discussed with the residents and/or responsible parties for four out of 14 sampled residents (Residents 17, 2, 22 and 24).
This failure had the potential for the facility to provide treatment and services against the residents' wishes.
Findings:
During a review of Resident 17's admission Record, dated 10/8/24, the record indicated Resident 17 was admitted to the facility with diagnoses that included aphasia following cerebral infarction (aphasia is a disorder that affects how a person communicates, cerebral infarction is a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die).
During a review of Resident 17's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/28/24, the MDS indicated Resident 17 had severe cognitive impairment.
During a review of Resident 17's Physician Orders for Life-Sustaining Treatment (or POLST, a form that gives instructions for the resident's care in life-threatening medical situations) form, dated 5/22/24, the POLST indicated advanced directive not available. Further review of Resident 17's medical record did not contain a copy of an advanced directive.
During a review of Resident 2's admission Record, dated 10/8/24, the record indicated Resident 2 was admitted to the facility on [DATE].
During a review of Resident 2's POLST form, dated 8/2/24, the form indicated Resident 2 had capacity to make decisions but indicated no information on the presence of an advanced directive.
During an interview on 10/9/24, at 3:31 p.m., with Social Serviced Director (SSD), SSD acknowledged she was not able to follow up with Resident 2's advanced directives.
During a review of Resident 22's admission Record, dated 10/8/24, the record indicated Resident 22 was admitted to the facility on [DATE].
During a review of Resident 22's POLST form dated 2/16/23, the form indicated no information on the presence of an advanced directive.
During a review of Resident 24's admission Record, dated 10/8/24, the record indicated Resident 24 was admitted to the facility on [DATE].
During a review of Resident 24's MDS dated [DATE], the MDS indicated Resident 24's cognition was moderately impaired.
During a review of resident 24's POLST form dated 4/24/23, the form indicated no information on the presence of an advanced directive.
During a concurrent interview and record review on 10/7/24, at 3:30 p.m., with SSD, Resident 17, 2, 22 and 24's medical records were reviewed. SSD stated advanced directives were discussed with the Resident 17, 2, 22, and 24's responsible parties, but SSD was not able to provide documentation.
During an interview on 10/9/24, at 3:31 p.m., with SSD, SSD stated the importance of advanced directive was for the residents' wishes regarding health decisions to be honored.
During an interview on 10/10/24, at 11:25 a.m., with the Director of Nursing (DON), the DON stated the importance of advance directives was to help ensure that the residents' wishes for medical care were carried out in case the resident becomes incapacitated.
During a review of the facility's policy and procedure (P&P) titled (Advanced Directives), indicated, . 3. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advanced directives. 4. Information about whether or not the resident has executed an advanced directive shall be displayed prominently in the medical record. 5. If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of two sampled residents' (Resident 4 and 2...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of two sampled residents' (Resident 4 and 21) rooms had comfortable and safe temperature levels.
This failure had the potential to cause overheating in residents and discomfort during severe hot weather.
Findings:
During a review of Resident 4's Annual Minimum Data Set (MDS - Resident assessment and care guide tool), dated 5/24/24, the MDS indicated Resident 4's Basic Interview of Mental status (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score was 14 and indicated intact mental status. The MDS indicated Resident 4 was able to recall the correct year and month. The MDS indicated Resident 4 had clear speech, able to express her ideas and wants, and understood what others said to her. Resident 4's diagnoses included stroke.
During a concurrent observation and interview on 10/08/24 at 8:03 a.m. Resident 4 laid in bed with loose-fitted clothes, awake and verbally responsive. Resident 4 stated her room was hot and uncomfortable in the afternoon despite the use of fan. Resident 4 stated her room temperature was 83 degree Fahrenheit (º F) at nighttime. Resident 4 stated she sweated through the night. Resident 4 said facility had no air conditioning. Resident 4 showed surveyor a table thermometer she kept at her bed side indicated room temperature was 80º F. Resident 4 said facility placed a fan in the hallway that blows hot air into her room. Resident 4 stated it was uncomfortable to sleep.
During a facility tour on 10/08/24 at 8:51 a.m. with Environment Supervisor (ES), observed one big standing fan in the hallway next to Resident 4's room. The following rooms air temperature were checked: Resident 4's room was 80.4 ºF, room [ROOM NUMBER] was 78ºF, room [ROOM NUMBER] was 80.9ºF, room [ROOM NUMBER] was 81.3ºF, room [ROOM NUMBER] was 80.ºF, and room [ROOM NUMBER] was 80.2º F.
During an interview on 10/8/24 at 8:51 a.m. with ES, ES stated facility had no air-conditioning. ES stated Certified Nursing Assistants (CNAs) informed him that residents' room [ROOM NUMBER] and 12 were hot. ES stated he checked room temperature and placed a fan close to the room. ES stated he did not document the temperature readings for residents' rooms.
During a review of Resident 21's Annual Minimum Data Set, dated [DATE], the MDS indicated Resident 21's Basic Interview of Mental status score was 14 and indicated intact mental status. The MDS indicated Resident 21 was able to recall the correct month and day of the week. The MDS indicated Resident 21 had clear speech, able to express her ideas and wants, and understood what others said to her. Resident 21's diagnoses included Asthma (a condition in which a person's airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe).
During a concurrent observation and interview on 10/08/24 10:01 a.m. with Resident 21, Resident 21 sat up in bed in her room, awake and verbally responsive. Resident 21 stated she wore loose clothing because it was hot in her room. Resident 21 stated at night she opened up all the windows in her room. Resident 21 stated it was uncomfortable to sleep.
During an interview on 10/8/24 at 9:21 a.m. with the Administrator (Admin), Admin stated she was aware that facility had no air conditioning. Admin stated she was concerned and provided in service to the staff about heat wave and what to do. Admin stated she discussed her concern with the management. Admin said facility will address what to do for nighttime heat.
During an interview on 10/08/24 at 12:05 p.m. with CNA 1, CNA 1 stated over the weekend room [ROOM NUMBER] was very hot on Saturday. CNA 1 stated the fan in resident room [ROOM NUMBER] was faulty and was not working. CNA 1 stated she asked laundry staff but there was no available replacement fan. CNA 1 stated she did not notify the charge nurse that room [ROOM NUMBER]'s fan was not working, and no replacement fan was available. CNA 1 stated she kept the residents' comfortable with light clothing.
During an interview on 10/08/24 at 12:10 p.m. with the Operations Manager (OPM), OPM stated the facility was an old building and did not have air-conditioning. OPM stated he had discussed issue of heat with the owner with consideration for installing air conditioning.
During a review of the National Weather Service (NWS) Advisory Hazardous Heat Warning, dated 10/5/24, the NWS indicated, Hazardous heat will be ever present this weekend. Dangerously hot conditions with temperatures up to 105º F. Excessive heat warning remains in effect for Alameda, Contra [NAME], San Francisco and Santa [NAME] counties. {Reference : https://x.com/NWSBayArea/status}.
During a review of the facility's policy and procedure (P&P) titled, Homelike Environment, undated, the P&P indicated: The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflects a personalized, homelike setting. These characteristics include: comfortable temperatures.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to use the communication binder (a communication visual t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to use the communication binder (a communication visual tool that is used to help residents communicate their needs) for three of three sampled non-English speaking or aphasic (a language disorder that affects how you communicate) residents (Resident 25, Resident 24, and 17) when:
1. Resident 25 and 24's communication binders were not used, and
2. Resident 17 did not have a communication binder.
This failure had the potential for Residents 25, 24 and 17 not to understand and carry out activities of daily living (ADL).
Findings:
1. During a concurrent observation and interview on 10/9/24, at 10:00 a.m., with Licensed Vocational Nurse (LVN) 1, in Resident 25's room, LVN 1 could not understand Resident 25 as Resident 25 spoke only in her native language. LVN 1 stated she could only communicate with Resident 25 through gestures and pointing. LVN 1 stated she did not know what language Resident 25 spoke.
During a review of Resident 25's admission Record, dated 10/10/24, indicated Resident 25 was admitted to the facility on [DATE] and the resident's primary language was [NAME] (language of the country [NAME]).
During a concurrent observation and interview on 10/9/24, at 10:40 a.m., with the Director of Nursing (DON), in Resident 25's room, the DON found Resident 25's communication binder inside Resident 25's bedside table drawer. The DON stated the binder should be on top of the bedside table so it was easily seen and used by staff.
During a review of Resident 24's admission Record, dated 10/10/24, the record indicated Resident 24 was admitted to the facility on [DATE] with diagnoses that included Dementia (memory loss and impaired decision-making capacity). The record further indicated Resident 24's primary language was Chinese.
During a review of Resident 24's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 4/19/24, the MDS indicated Resident 24's cognition was mildly impaired.
During a concurrent observation and interview on 10/9/24, at 10:09 a.m., with the DON, in Resident 24's room, the DON found Resident 24's communication binder inside Resident 24's bedside table drawer.
During an interview on 10/10/24, at 10:30 a.m., with the Certified Nursing Assistant (CNA) 3, stated he could only communicate with the resident through gestures and pointing. CNA 3 stated he did not know that the resident had a communication binder.
2. During a review of Resident 17's admission Record, dated 10/10/24, the record indicated Resident 17 was admitted to the facility on [DATE] with diagnoses that included aphasia following cerebral infarction (aphasia is a disorder that affects how a person communicates, cerebral infarction is a serious condition that occurs when blood flow to the brain is blocked, causing brain tissue to die).
During a review of Resident 17's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 6/28/24, the MDS indicated Resident 17 only sometimes understood others and was only sometimes understood by others.
During a concurrent observation and interview on 10/9/24 at 10:45 a.m., with the DON in Resident 17's room, the DON could not find Resident 17's communication binder. DON further stated Resident 17 was supposed to have the communication binder at bedside to be able to communicate needs.
During a review of the facility's policy and procedure (P&P) titled (dignity and communication), indicated, . 6. Residents who speak a different primary language other than the primary language of the facility can use some of the following resources: a. translators, including language applications for real-time translations. b. language communication boards .
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility had one residents' room (room [ROOM NUMBER]) with multiple beds that provided l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility had one residents' room (room [ROOM NUMBER]) with multiple beds that provided less than 80 square foot (sq. ft) per resident who occupied this room.
This failure had the potential to result in inadequate space for the delivery of care to each of the residents in each room or for storage of residents' belongings.
Findings:
During an observation on 10/8/24 at 12:14 p.m., in room [ROOM NUMBER], in the presence of Certified Nursing Assistant (CNA) 1, room [ROOM NUMBER]'s corresponding sq. ft per bed was identified:
Room Floor Area
12 76.26 sq. ft
During an observation on 10/8/24 at 12:14 p.m., room [ROOM NUMBER] had two beds with residents laid in bed awake and nonverbal.
During a concurrent observation and interview on 10/8/24 at 12:15 p.m. with CNA 1 in room [ROOM NUMBER], CNA 1 stated there was enough space to conveniently provide care for residents in the rooms and for residents that needed Hoyer lift. CNA 1 stated bed was lowered and moved to use the Hoyer lift. CNA 1 stated there was no heavy equipment kept in the room that might interfere with residents' care and each resident had adequate personal space and privacy. There were no negative consequences attributed to the decreased space in room [ROOM NUMBER]. Granting of room size waiver recommended.
Nov 2023
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one (Resident 24) sampled resident's Pre-admission Screening Resident Review (PASRR) for serious mental illness was accurately compl...
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Based on interview and record review, the facility failed to ensure one (Resident 24) sampled resident's Pre-admission Screening Resident Review (PASRR) for serious mental illness was accurately completed and referred to the appropriate state mental authority for Level II evaluation and determination.
This failure had the potential to prevent Resident 24 from receiving appropriate required mental health services.
Findings:
Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 10/13/23, indicated the PASRR was coded zero-meaning, Resident 24 was not considered by the State Level II PASRR process to have a serious mental illness. However, Resident 24's diagnoses included Bipolar disorder (mood disorder associated with episodes of mood swings ranging from depressive lows to manic highs).
Review of the PASRR screening dated 9/13/22 indicated Resident 24 did not have a diagnosed mental disorder such as depression, anxiety, panic and/or mood disorder.
During an interview and concurrent record review, on 11/14/23 at 11:10 a.m., with Registered Nurse/MDS coordinator (MDS), MDS stated the Administrator (Admin) or designee was responsible for completing the PASRR. MDS stated Resident 24's PASRR was not completed accuratelyand Resident 24 diagnosis included Bipolar disorder a mental illness. MDS further stated Resident 24 was not referred to the State Mental Authority for specialized mental health services.
During an interview on 11/15/23 at 9:28 a.m., Admin stated he or the Business Office Manager completed the residents' PASRRs. Admin stated he did not recognize that Resident 24's diagnosis included Bipolar disorder when the PASRR was completed.
Review of the facility's policy and procedure titled, PASRR Screening (undated), indicated the facility will complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement the nutritional interventions for one (Resident 29) of one sampled resident with significant weight loss.
This failure had the p...
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Based on interview and record review, the facility failed to implement the nutritional interventions for one (Resident 29) of one sampled resident with significant weight loss.
This failure had the potential to result in continuous weight loss, fluid imbalance, and dehydration.
Findings:
Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 8/18/23, indicated Resident 29 had weight loss of 5% or more in the last month or loss of 10% or more in the last six months. Resident 29 was not on a physician-prescribed weight-loss regimen. Resident 29 had diagnoses that included heart failure (e.g. congestive heart failure or CHF and pulmonary edema- a chronic condition in which the heart doesn't pump blood as well as it should) and diabetes mellitus (high blood sugar).
Review of the weight and vital summary, dated 4/1/2023 through 11/30/2023, indicated Resident 29's weight record as follows:
4/2/23 - 89 lb
7/7/23 - 80 lb
10/1/23 - 75.9 lb
11/5/23 - 71.4 lb
Review of the Nutrition/Dietary Notes dated 10/13/23, indicated Resident 29 has a significant weight loss of 7.4 lb weight loss in 90 days and 13.4 lb weight loss in 180 days. Resident 29 ate on average, 25% of meals during the last 14 days. Resident 29 refused 3 meals during the last 14 days. The interventions included a liberalized diet, provide magic cup (reduced sugar) daily, provide diabetic snack at hour of sleep, honor resident's food and beverage preferences, Med Plus 2.0 (4 oz) twice a day, provide high caloric snacks in between meals, Vitamin C 500 mg (milligram) or anemia, folate, iron, and B 12 supplements for anemia, check for dehydration signs and symptoms, fluids less or equal to 1,450 ml (milliliter) /day (CHF), 800 ml/day from nursing (staff) and 2-3 cups/day from dietary.
Review of the unplanned weight loss care plan initiated 12/13/22, indicated Resident 29 had unexpected weight loss related to poor meal intake, and interventions included to alert the dietician if consumption is poor for more than 48 hours, and if (weight) loss persists, contact the physician and dietician immediately and offer substitutes as requested or indicated.
During an interview on 11/15/23 at 12:16 p.m., with Registered Dietician (RD), RD stated Resident 29 had significant weight loss. RD stated Resident 29 had an individual, liberalized diet and on comfort care. RD stated she expected staff to implement Resident 29's nutrition interventions, including fluid requirement due to diagnosis of CHF. RD stated she expected a fluid intake record to be kept in Resident 29 medical records. RD stated she communicated Resident 29's nutrition interventions with the Director of Nursing (DON), Dietary Supervisor (DS) and Administrator(Admin).
During an interview and concurrent record review on 11/15/23 at 2:12 p.m., with Registered Nurse (RN 1), RN 1 stated she was not aware Resident 29's fluid intake needed to be recorded and was not recorded or aware of the 10/13/23 nutrition interventions.
During an interview and concurrent review of Resident 29's nutrition interventions, on 11/15/23 at 2:30 p.m., DON stated Resident 29's nutrition interventions were not acted upon because Resident 29 was on comfort care and and there was no need to monitor Resident 29's fluid intake. DON stated the RD and physician were not informed that Resident 29's nutrition interventions would not be acted upon.
During an interview on 11/16/23 at 9:09 a.m., DON stated RD notified her of Resident 29 nutrition interventions and recommendations. DON stated Resident 29's nutrition interventions were not implemented or acted upon.
Review of the facility's policy and procedure titled, Weight Assessment and Intervention, undated, indicated the interdisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents.
Interventions for undesirable weight loss shall be based on careful consideration of the followings:
a. Resident choice and preferences;
b. Nutrition and hydration needs of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (Resident 20) of five sampled residents was free from u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (Resident 20) of five sampled residents was free from unnecessary drugs when the pharmacist's recommendation for reviewing the justifciation of the continued use of Benadryl (antihistamine/allergy) medication ordered PRN (as needed) was not acted upon.
Definition: Benadryl is an antihistamine drug use for relief of allergic symptoms with warning that included central nervous depression which may impair physical or mental abilities, patient must be caution about performing tasks that required alertness}. Reference: https://online.[NAME].com.
This failure had the potential for adverse medication side effects and not identifying other causes of itchy skin (dry skin, allergic reactions or other skin conditions).
Findings:
Review of the Minimum Data Set (MDS - an assessment screening tool used to guide care), dated 9/27/23, indicated Resident 20 had diagnoses that included chronic lung disease. Resident 20 was on hospice (end-of life) care.
Review of the physician order dated 6/23/2023 indicated Resident 20 to receive Benadryl allergy oral tablet 25 mg (mill8gram) give one tablet by mouth every 4 hours as needed for itching.
Review of the Medication Administration Record (MAR), dated 10/1/2020 through 10/31/2023, indicated Resident 20 received Benadryl 25 mg one tablet as needed one to three times a day for itching. Further review of the MAR, dated 11/1/23 through 11/1/15, indicated Resident 20 received Benadryl 25 mg one tablet as needed one to two times a day.
Review of the Consultant Pharmacist (CP) Medication Regimen Review (MRR) dated 9/8/23 indicated Resident 20 has been taking Benadryl mostly at bedtime for itching. Please clarify the reason for this condition and if there is any other treatment we are doing to resolve this condition.
During a review of Resident 20's MRR and concurrent interview on 11/14/23 at 12:52 p.m., with the Director of Nursing (DON), DON stated for Resident 20, CP's recommendations dated 9/8/23 was not acted upon. DON stated there was no stop date for Benadryl as needed because Resident 20 continued to request Benadryl. DON further stated there was no monitoring of Benadryl for adverse side effects.
During an interview on 11/16/23 at 9:59 a.m., with Registered Nurse (RN 1) RN 1 stated when an as needed order has no stop date, the physician will be called for clarification. RN 1 said Resident 20 was on hospice care. RN 1 stated she did not know what to do regarding as needed medication orders for residents on hospice care.
Review of the facility's policy and procedure, Titled, Medication Regimen Review undated indicated, the primary purpose of this review is to help the facility maintain each resident's highest practicable level of functioning by helping them utilize medication appropriately and prevent or minimize adverse consequences related to medication therapy to the extent possible.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0572
(Tag F0572)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform residents in a language they understood of their rights, all...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to inform residents in a language they understood of their rights, all rules and regulations governing residents conduct and responsibilities during their stay at the facility for nine of nine sampled residents (Resident 5, 6, 8, 11, 21, 24, 25, 27 and 133), who were identified as Chinese speaking residents.
A California ombudsman essentially helps senior victims of abuse or neglect to understand their rights within the legal system and reach a proper resolution}.
This failure had the potential to cause residents emotional distress and despair.
Findings:
Review of the admission record indicated Resident 21 was Chinese and their primary language is Chinese. Resident 21 was admitted to the facility on [DATE].
During a resident council meeting on 11/14/23 at 10:04 a.m., through a phone translator (PTL), Resident 21 stated he did not know who to talk to when he had grievances. Resident 21 stated he did not know about the Ombudsmen or their phone numbers. (A California Ombudsman essentially helps senior victims of abuse or neglect to understand their rights within the legal system and reach a proper resolution}. Through the PTL, Resident 21 stated the Ombudsman poster should be written not only in English but written in traditional and simplified Chinese language.
During an interview and concurrent review of the Residents [NAME] of Rights, on 11/15/23 at 10:00 a.m., the Administrator (Admin) stated Resident 21's primary language is Chinese. Admin stated the Resident [NAME] of Rights provided to Resident 21 at the time of admission to the facility was in English and not in a language Resident 21 understood. Furthermore, Admin identified Residents 5, 6, 8, 11, 21, 24, 25, 27 and 133 as having Chinese as their primary language and were not informed of their bill of rights in a language they understood. Admin stated the facility will request for an Ombudsmen poster with Chinese translation.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure storage of food under sanitary conditions when;
- one carton of thickened Apple Juice from concentrate was opened with no use- by-date...
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Based on observation and interview, the facility failed to ensure storage of food under sanitary conditions when;
- one carton of thickened Apple Juice from concentrate was opened with no use- by-date;
- three containers of mayonnaise opened with no use-by-date;
- five brownish, discolored juice cups ready for use;
- one container of chopped garlic in oil opened with no use- by-date;
- staffs' personal food items of tea, cooked eggs and cell phone were placed on the kitchen preparation table;
- two bags of vegetables placed on the 2-compartment sink next to dishwashing area.
These failures had the potential to result in food borne illness for residents who received food from the facility's kitchen.
Findings:
During the initial tour of the kitchen on 11/13/23 at 9:10 a.m., accompanied by the Dietary Manager (DM), the following were observed: one cartoon of thickened Apple Juice from concentrate was opened with no use- by-date; three containers of mayonnaise opened had no use-by-date;
five brownish discolored juice cups ready for use, and one container of chopped garlic in oil opened with no use- by-date.
During a follow up visit to the kitchen on 11/13/23 at 10:18 a.m., accompanied by DM, observed staffs' food items of tea, cooked eggs, cell phone placed on the kitchen table and two bags of vegetable were placed on the two compartment sink next to the dishwasher.
During an interview on 11/13/23 at 10:18 a.m., DM stated the cooked eggs, cup of tea, and cell phone belonged to staff. DM stated staff are not allowed to eat in the kitchen. DM said the two-compartment sink are supposed to be used for dish washing during emergencies.
During an interview on 11/14/23 at 11:31a.m., [NAME] (CK), CK stated the two-compartment sink was used for thawing food items, such as meat, vegetables etc.
During an interview on 11/16/23 at 9:48 a.m., DM stated the kitchen did not have enough space for a food prep sink and that was the reason the vegetable and meat are thawed in the two- compartment sink.
Mar 2022
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident 23) received the necessary services to maintain personal hygiene when Resident 2...
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Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident 23) received the necessary services to maintain personal hygiene when Resident 23 did not receive incontinent (inability to hold urine or bowels) care.
This deficient practice had the potential to make Resident 23 feel the lack of dignity and respect.
Findings:
During an interview on 2/22/22, at 11:15 a.m., with Resident 23, Resident 23 stated, there was an incident during the night shift when Resident 23 called a certified nursing assistant (CNA) to help with emptying Resident 23's colostomy bag (a plastic bag that collects fecal matter from the digestive tract through an opening in the stomach wall called a stoma). Resident 23 further stated, the CNA came to the room, handed Resident 23 the bedpan and gloves, and the CNA left the room without assisting Resident 23 with emptying the colostomy bag.
During an interview on 2/23/22, at 6:44 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated, Resident 23 usually calls at night to request staff help hold the bedpan (receptacle used by a bedridden patient as a toilet) while Resident 23 empties the colostomy bag contents into the bedpan.
During a concurrent observation and interview on 2/25/22, at 8:33 a.m., in Resident 23's room, Resident 23 stated, staff does not help with incontinence care. Resident 23 was observed to asking Certified Nursing Assistant 3 (CNA 3) to hold the bedpan for Resident 23 to empty their colostomy bag contents into the bedpan. CNA 3 was observed stating she did not want to hold the bedpan for Resident 23.
During an interview on 2/25/22, at 10:04 a.m., with the Director of Nursing (DON), the DON stated, we empty the colostomy bag for Resident 23. The DON further stated, sometimes Resident 23 can empty the colostomy bag but staff has to help Resident 23.
During a review of Resident 23's Minimum Data Set (MDS, a comprehensive health assessment) Section H - Bladder and Bowel, dated 1/17/22, the MDS Section H indicated, Resident 23 has an ostomy for bowel continence.
During a review of Resident 23's MDS Section G - Functional Status, dated 1/17/22, the MDS Section G indicated, Resident 23's needs one-person physical assistance for toilet use.
During a review of the facility's policy and procedure (P&P) titled, Resident Activities of Daily Living (ADL-term used in healthcare to refer to people's daily self-care activities), (undated), the P&P indicated, Each resident shall be offered and provided ADL support, while maintaining their highest practicable function, with safety, comfort and dignity. P&P also indicated If the resident has difficulty performing the activity or does not perform the activity, they may be assisted with appropriate care staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to record and document one controlled medication (medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to record and document one controlled medication (medication with potential or risk for abuse) when Norco (medication for severe pain) was not recorded and documented on the facility's Narcotics (a drug or substance that affects mood or behavior) Log for one of 12 sampled residents (Resident 26).
This deficient practice had the potential for loss or diversion of Resident 26's pain medication.
Findings:
A record review of Resident 26's admission Record, dated 2/24/22, indicated Resident 26 was admitted on [DATE]. The admission Record also indicated Resident 26 had medical diagnoses including multiple fractures (broken bones) of ribs and a history of falls.
A Record Review of Resident 26's Order Summary, dated 2/24/22, indicated Resident 26 had a physician's order, dated 2/2/22, for Norco Tablet 5-325 milligram (mg) one tablet by mouth two times a day for pain.
During a concurrent observation, interview, and record review on 2/23/22, at 9:46 a.m., with Licensed Vocational Nurse (LVN 1), the Individual Patient's Narcotic Record, signed by the nurse receiving the Norco medication on 2/3/22 was reviewed. Resident 26's Narcotic Record for Norco 5-325 Tablet indicated one Norco tablet was not recorded and documented. Resident 26's Narcotic Record indicated, 19 Norco tablets were administered to Resident 26. Resident 26's Norco bubble pack (a medication pack containing designated sealed compartments for medication to be taken at a particular time of time of the day) was observed with 20 Norco tablets dispensed. LVN 1 stated, she counted the Norco at the start of her shift, and she missed one dose.
During a concurrent interview and record review on 2/23/22, at 10:19 a.m., with LVN 1, LVN 1 stated, she forgot to document the Norco she gave Resident 26 on 2/22/22. LVN 1 further stated she corrected Resident 26's Narcotic Record. Review of Resident 26's Narcotic Record indicated 20 Norco tables were administered.
A record review of Resident 26's Medication Administration Record (MAR) indicated Resident 26 received one Norco 5-325 Tablet on 2/22/22, at 9:00 a.m.
During an interview on 2/25/22, at 12:10 p.m. with the Director of Nursing (DON), the DON stated, the narcotics count, and documentation are done between each shift. The DON further stated, it is important to document the narcotic count because the medication can be missing.
During a record review of the facility's policy and procedure (P&P) titled, Controlled Substance Policy, dated 2007, the P&P indicated, when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage . a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat one of 12 sampled residents (Resident 27) with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat one of 12 sampled residents (Resident 27) with respect and dignity when:
1. Resident 27 had a clothing protector, commonly known as bib on for over three hours after breakfast hours; and
2. Registered Nurse (RN 1) addressed Resident 27 as [NAME] during incontinent care.
These failures resulted in Resident 27 to not receive individualized care and had potential for Resident 27 to not feel respected.
Findings:
During a record review of Resident 27's admission Record dated 2/23/22, it indicated Resident 27 was admitted to the facility on [DATE].
During a record review of Resident 27's Annual Minimum Data Set (MDS- an assessment used to plan care) dated 1/27/22, the MDS assessment indicated, Resident 27's Brief Interview for Mental Status (BIMS- an assessment for cognition status) score was five (5) out of 15, indicating severe mental impairment.
1. During an observation on 2/22/22, at 10:03 a.m., Resident 27 was sitting in a wheelchair outside his room. Resident 27 had a large towel clothing protector on around his neck, covering his chest.
During another observation on 2/22/22, at 11:15 a.m., Resident 27 still had the clothing protector on while he was sitting in his wheelchair by his bed.
During an observation and interview on 2/22/22, at 11:35 a.m., Resident 27's clothing protector was on his bedside table. RN 1 stated she removed Resident 27's clothing protector when she provided incontinent care to him. RN 1 stated, we always put the bib [clothing protector] because he [Resident 27] drools a lot and spits on the floor.
During an interview on 2/22/22, at 1:58 p.m., the Director of Nursing (DON) stated staff put the clothing protector on residents before they eat and removed when residents were done eating. The DON stated it was a resident's dignity issue if clothing protector was not removed after Resident 27 was done eating his breakfast. The DON stated facility served breakfast around 8:00 a.m. that day.
2. During an observation on 2/22/22, at 11:20 a.m., RN 1 provided incontinent care and changed Resident 27's incontinent briefs. RN 1 was observed addressing Resident 27 as [NAME] while transferring Resident 27 from wheelchair to the bed. RN 1 pulled the privacy curtain and stated, [NAME] lay down for me .okay [NAME] turn around .
During an interview on 2/22/22, at 1:58 p.m., with the DON, the DON stated, staff was expected to call the residents by first or last name and it was not okay to address the residents as mama or [NAME] unless that was resident's preference. The DON stated resident's preferences were documented under care plan section in the electronic medical record. The DON also stated staff was expected to respect the residents.
During an interview and concurrent record review with the DON, on 2/22/22, at 2:04 p.m., Resident 27's care plans in the electronic medical record were reviewed. The DON stated Resident 27's care plans did not indicate if Resident 27 preferred to keep the clothing protector on for longer hours and/ or if Resident 27 preferred the facility staff to address him as [NAME].
During a record review of facility's undated policy and procedures titled, Quality of Life- Dignity indicated, Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality .Residents shall be treated with dignity and respect at all times .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure privacy and confidentiality of medical information for two of two sampled residents (Residents 23 and 30) when:
1. Resident 30's elect...
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Based on observation and interview, the facility failed to ensure privacy and confidentiality of medical information for two of two sampled residents (Residents 23 and 30) when:
1. Resident 30's electronic medical record was left exposed at Medication Cart 1; and
2. Certified Nursing Assistant 3 (CNA 3) did not provide privacy during toileting for Resident 23.
These failures had the potential for unauthorized access to Resident 30's medical information and it violated resident's right to privacy for Resident 23.
Findings:
1. During a concurrent observation and interview on 2/25/22, at 9:33 a.m., with Licensed Vocational Nurse 2 (LVN 2), the computer screen was observed open to Resident 30's medical record on Medication Cart 1. The computer screen was also observed exposing Resident 30's name, vital signs, physician name, allergy status, code status, photo, care plan, and pain assessment. LVN 2 stated Resident 30's record should have been secured when she stepped away from the cart.
During an interview with the Director of Nursing (DON) on 2/25/22, at 9:48 a.m., the DON stated there is a button on the computer screen for staff to use that secures the computer screen when they step away from the workstation. The DON further stated securing the computer displaying resident personal and medical information is important because the Health Insurance Portability and Accountability Act (HIPAA) requires medical records be kept confidential. 2. During an observation on 2/25/22, at 8:33 a.m., Resident 23 requested assistance from Certified Nursing Assistant (CNA 3) in emptying the colostomy bag (a bag attached to an opening into the abdomen to excrete the fecal matter). Resident 23 was in lying position. Resident 23 removed the blanket from the lower part of his body while his legs and colostomy were exposed. CNA 3 handed a bed pan to Resident 23 and told him to put it in between his legs right above the genital area. Resident 23's bed was right by the door, which was wide open. CNA 3 did not pull the privacy curtain while Resident 23 emptied the colostomy bag.
During an interview with CNA 3 and Resident 23 on 2/25/22, at 8:45 a.m., at Resident 23's bedside, CNA 3 apologized for not pulling the privacy curtain during colostomy care. Resident 23 stated he would like the staff to pull the privacy curtain to provide him privacy during colostomy care.
During a record review of the facility's undated policy and procedure (P&P) titled, Dignity and Privacy During Care, the P&P indicated, Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a home like environment to five of 12 sampled...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a home like environment to five of 12 sampled residents (Resident 1, 23, 2, 8 and 30) when:
1. the room temperature for Resident 1 and 23 were too cold; and
2. the overbed tables for Residents 2, 8 and 30 were rough and unfurnished.
The above failures resulted in Resident 1 and 23 feeling cold, and the potential for Residents 2, 8 and 30 getting scratched and hurting themselves.
Findings:
1. A record review of Resident 1's admission Record dated 2/24/22, indicated Resident 1 was admitted on [DATE].
A record review of Resident 27's admission Record dated 2/25/22, indicated Resident 27 was admitted on [DATE].
During an interview on 2/22/22 1:02 p.m., Resident 1 stated that her room is always too cold, and she doesn't like it.
During an observation and interview on 2/23/22, at 12:25 p.m., with the ADM (Administrator), the ADM stated the facility temperature is kept around 70ºF (degrees Fahrenheit). The ADM stated the nurses are responsible for changing the temperature if residents make a complaint or have a request. The ADM stated there are no temperature check logs for resident rooms. The ADM measured the temperatures of the following rooms: room [ROOM NUMBER] was 69.3º F, room [ROOM NUMBER] was 69.3ºF, and room [ROOM NUMBER] was 69.3ºF.
During an interview on 2/25/22, at 1:23 p.m., Resident 23 stated, his room is too cold, all the time. Resident 23 further stated, it makes him feel his room is not homelike.
A review of the facility's policy and procedure (P&P) titled, Homelike Environment, (undated), indicated, The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .Comfortable temperatures.
2. During an observation with Certified Nursing Assistant 1(CNA 1) on 2/24/22, at 9:07 a.m., Resident 30's overbed table [a table with metal base with four wheels, a metallic leg on one side and a wooden tray on the top] was at her bedside. All four sides of the top wooden tray of the table were unfurnished, uneven and rough to touch. CNA 1 stated Resident 30 used the overbed table daily. When asked about her thoughts about overbed table being unfurnished and rough to touch, CNA 1 stated, what can I say.
During an observation with Registered Nurse (RN 1) on 2/24/22, at 9:58 a.m., in Resident 30's room, RN 1 stated, most of them [overbed tables] were old in the facility. RN 1 stated, because the overbed tables were rough and uneven, that could scratch resident's hands. RN 1 stated, staff reported the facility's administration of furniture repairs needs back in 12/2021 [almost two months ago].
During another observation with RN 1 and CNA 2 on 2/24/22, at 10:04 a.m., Resident 8 and Resident 2's overbed tables were observed. The edges of the top wooden tray for Resident 8 and Resident 2 were scratched, uneven and rough to touch. The top wooden tray for Resident 8's table also had multiple chipped areas. CNA 2 stated, it could crack resident's body, we don't like it.
During an interview with the Director of Nursing (DON) on 2/24/22, at 10:28 a.m., the DON stated, to ensure resident's safety, the facility checks the resident's surroundings every day, but did not notice the unfurnished overbed tables for Resident 30, 8 and 2. The DON stated unfurnished furniture's wooden particles could get mixed in resident's food and cause injuries to Resident 30, 8 and 2.
During an interview and record review with the Assistant Administrator (AADM) on 2/24/22, at 11:11 a.m., the facility's Maintenance Log binder was reviewed. AADM stated, he did resident room rounds every six (6) months and the maintenance supervisor was responsible for daily rounds to ensure residents' surroundings were safe. The AADM opened the Weekly Over Bed Table Log for the month of January 2022, a section of the Maintenance log binder indicated the maintenance supervisor did not check the overbed tables for all residents after 1/27/22. The weekly overbed table log indicated, Examine all overbed tables weekly to ensure they are clean and in good repair. Wheels are clean and roll smoothly. Note location of table and comment on repairs made or need to discard or replace. AADM stated, the log did not indicate if overbed tables for Resident 30, 8 and 2 required repairs or needed to be replaced and the comment section was left blank. The AADM also stated, he did not think overbed tables for Resident 30, 8 and 2 turned into an unfurnished condition just in one month. The AADM stated, the maintenance supervisor was not available during the survey week.
During a record review of the facility's undated policy and procedure (P&P) titled, Homelike Environment, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment .2 .The facility staff and management shall maximize to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: .d. Personalized furniture and room arrangements .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure its medication error rate did not exceed five perc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure its medication error rate did not exceed five percent for one of 12 sampled residents (Resident 27). There were four medication errors out of 25 opportunities resulting to 16 percent (%) medication error rate when Resident 27's percutaneous endoscopic gastrostomy tube (PEG tube, a feeding tube placed through the abdominal wall and into the stomach that allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth ) was not flushed (inserting a liquid substance into a tube, usually ) with water in between administering Apixaban (blood thinner medication), Ascorbic Acid (Vitamin C supplement), Doxazosin Mesylate (high blood pressure and urinary retention medications), and Vitamin D3 (Vitamin D supplement).
This practice had the potential to jeopardize Resident 27' health, obstruct Resident 27's PEG tube, and cause unnecessary pain and discomfort to Resident 27.
Findings:
A record review of Resident 27's admission Record dated 2/24/22, indicated Resident 27 was admitted on [DATE]. The admission Record also indicated, Resident 27 has medical diagnoses including: Vitamin D deficiency (low Vitamin D in the body that can lead to a loss of bone density, which can contribute to a break in the bone), neuromuscular dysfunction of bladder (body lacks bladder control), and hypertension (high blood pressure).
A record review of Resident 27's Order Summary dated 2/23/22, indicated a physician's order for:
1.
Apixaban Tablet 5 mg (a blood thinner medication used to treat and prevent blood clots and prevent stroke) and to give one tablet via PEG tube,
2.
Ascorbic Acid Tablet 500 mg (Vitamin C supplement) and to give one tablet via PEG tube,
3.
Doxazosin Mesylate Tablet one mg (a medication used to treat urinary problems and high blood pressure) and to give one tablet via PEG tube,
4.
Vitamin D3 Tablet (Vitamin D supplement) and to give 50000 units via PEG tube, and
5.
to flush the PEG tube with 30 cc (cubic centimeter) of water pre and post medications.
During a concurrent observation and interview on 2/23/22, at 08:55 a.m., with RN 1, RN 1 was observed preparing and administering medications for Resident 27. RN 1 combined and crushed the following medications together at one time: one 5 mg Apixaban tablet, one 500 mg Ascorbic Acid tablet, one 1 mg Doxazosin Mesylate tablet, and one Vitamin D3 tablet. RN 1 poured the combination of crushed medications in one cup and added water. RN 1 checked Resident 27's PEG tube residual (fluid or contents that remain in the stomach) and flushed it with 30 cc of water. RN 1 administered the combination of medications to Resident 27 via PEG tube. After administering approximately half of the medication mixture RN 1 added additional water to the medication, then continued administering the rest of the medication mixture. RN 1 did not flush Resident 27's PEG tube with water after she was done administering the medication mixture. RN 1 stated, she did not flush the PEG tube after giving all the medications because she added 30cc of water to the medication mixture while she was administering it.
During an interview on 2/25/22, at 9:40 a.m., with the DON (Director of Nursing), the DON stated that the facility's policy was to flush PEG tubes with 30 cc of water before giving medications and after giving medications. The DON stated the facility's policy is to crush medications individually. The DON stated the facility's policy is to administer each medication separately when administering medications via PEG tube to prevent obstruction.
A record review of the facility's policy and procedure (P&P) titled, Medication Administration Enteral Tubes, dated 2007, the P&P indicated, .crushed medications should not be combined and given all at once via feeding tube . crushed medications are not mixed together .each medication is administered separately to avoid interaction and clumping . enteral tubes are flushed with at least 15mL [milliliter - often referred to as cc] of water before administering any medications and after all medications have been administered.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the lunch menu for 12 of 12 sampled residents (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the lunch menu for 12 of 12 sampled residents (Residents 31, 26, 28, 8, 2, 17, 24, 30, 20, 11, 5, 1, 19, 14 and 7) and the Dietary Department did not notify the residents of the menu change.
This deficient practice resulted in Residents 31, 26, 28, 8, 2, 17, 24, 30, 20, 11, 5, 1, 19, 14 and 7 not knowing what food items they were getting for lunch and had the potential for residents not to get the nutritional value of the food item that was on originally on the menu.
Findings:
During a concurrent observation and interview on 2/22/22, at 11:52 a.m., with the Dietary Manager (DM), in the kitchen, it was observed that meatballs, spiral pasta and broccoli with other vegetables were being prepared. The DM stated the chicken was still frozen, they do not have broccoli, and he could not find the couscous. The DM stated he replaced the chicken with turkey meatball, replaced the broccoli with a broccoli mixed blend, and replaced the couscous with spiral pasta. The DM stated he did not notify the residents of the menu change.
During an interview on 2/22/22, at 12:22 p.m., with Resident 28, Resident 28 stated, she was not notified of the change in the menu for lunch. Resident 28 further stated, she never knows what is on the menu and if she does not like the food served, she requests for soup.
During an interview on 2/22/22, at 12:30 p.m., with Resident 23, Resident 23 stated, he was not notified by anyone on the changes in the lunch menu for today. Resident 23 further stated, he just ate the meatballs and a little bit of the broccoli.
During a review of the Winter Menu Week 3, undated, the Winter Menu Week 3 indicated, for noon on Tuesday (2/22/22) the following is on the lunch menu: Middle Eastern Chicken, Orange Zest Couscous, Broccoli with Red Peppers and Peach [NAME].
During a review of the facility's policy and procedure (P&P) titled, Menu Changes, dated 2014, the P&P indicated, When items on the menu are not available, due to an unavoidable circumstance, as a last alternative, a substitute from the same food group is permissible. The substitution must be of equal nutritional value. Any menu change must be documented according to these procedures.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review the facility failed to follow the physician's order to provide a fortified diet (food that has extra nutrients added to it or has nutrients added tha...
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Based on observation, interview, and record review the facility failed to follow the physician's order to provide a fortified diet (food that has extra nutrients added to it or has nutrients added that are not normally there) for two of 12 sampled residents (Residents 5 and 28).
This deficient practice had the potential to cause Residents 5 and 28 to experience weight loss and to not meet or maintain their ideal body weight.
Findings:
During a concurrent observation and interview on 2/22/22, at 12:05 p.m., with the Dietary Manager (DM), Resident 5's meal tray on the kitchen cart was observed to not have any butter on it. The DM stated, they add butter to the plate for residents who have fortified diets.
During a review of Resident 5's Order Summary Report, dated 2/25/22, the Order Summary Report indicated, Resident 5 was on a fortified diet.
During an observation on 2/22/22, at 12:22 p.m., in Resident 28's room, Resident 28's lunch tray was observed on the overbed table with a diet card indicating Resident 28 was on a fortified diet. Resident 28's lunch tray was observed without butter on it. Resident 28 further stated she does not know what she gets on her meal tray.
During a review of Resident 28's Order Summary Report, dated 2/25/22, the Order Summary Report indicated, Resident 28 was on a fortified diet, mechanical soft, ground meat texture, thin consistency, moist food diet.
During an interview on 2/24/22, at 9:03 a.m., with the Registered Dietician (RD), the RD stated, it is extremely important to follow prescribed therapeutic diets. The RD stated not getting recommended diets might result in residents losing weight, not being able to function at their best, and wounds not healing.
During a review of the facility's policy and procedure (P&P) titled, Resident's Rights and Responsibilities Related to Food Policy No. 390, dated 2014, the P&P indicated, The resident has the right to receive a therapeutic diet when there is a medical problem indicating the need for adjustment from the regular diet.
During a review of the facility's P&P titled, Fortified Diet to Increase Calories and Protein, dated 2013, the P&P indicated, Fortified diet provides additional calories and protein in the same manner or a smaller volume at mealtimes than the Regular Diet.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when:
1. an opened lemon juice bottle, thre...
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Based on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when:
1. an opened lemon juice bottle, three turkey meat slices wrapped in foil, and one turkey pack with no open date were found in Refrigerator 2 (Ref 2),
2. one sliced banana in plastic wrap and five slices of oranges in an uncovered bowl with no prepared date were found in Refrigerator 1 (Ref 1),
3. one overripe banana was in Ref 1 and 11 overripe bananas was in the dry storage room,
4. Ref 1 had black crumbs on the door latch and had dried liquid drippings on Ref 1's back wall,
5. the can opener had dried matter and white hair stuck on it,
6. the dry storage area did not have a thermometer,
7. staff did not wash their hands and change gloves in between touching food items, handles, and their face mask; and
8. staff did not properly cover their hair with a hairnet.
These failures placed the residents at risk for food borne illnesses.
Findings:
1. During an initial tour of the kitchen with the Dietary Manager (DM) on 2/22/22, at 9:59 a.m., inside Ref 2, an opened bottle of lemon juice was observed with no labelled opened date on it. The DM was observed unwrapping a foil wrapped object with no date on it, revealing three turkey meat slices in it, and throwing the turkey meat slices in the trash bin. DM stated the undated and opened pack of turkey in Ref 2 should have been dated.
2. During the kitchen's initial tour with DM, on 2/22/22, at 9:49 a.m., inside Ref 1, one sliced overripe banana was observed in a plastic wrap with no date prepared. The DM stated they use the banana for cereal or for pureed diet and the DM stated he was going to throw it out. Further observation noted an uncovered bowl with 5 slices of orange in it without the preparation date on it. The DM stated it was fresh fruit and it was extra.
During a review of the facility's policy and procedure (P&P) titled, Storage of Food and Non-Food Supplies, dated 2014, the P&P indicated, Opened containers of food will be stored in tightly closed non-corrosive containers or in sealed plastic bags. No exposed food will be stored in the storeroom, refrigerators, or freezer. Open and use-by-dates will be placed on these items.
3. During the kitchen's initial tour with DM, on 2/22/22, at 9:49 a.m., it was observed that one cut overripe banana with black spots on the banana was stored in Ref 1 and 11 overripe, black-spotted bananas were stored in the dry storage room. The DM was observed peeling a banana and the DM stated, the banana is overripe because it had a black soft area inside of it.
During a review of the facility's P&P titled, Storage of Food and Non-Food Supplies, dated 2014, the P&P indicated, 2.) Bananas are stored at room temperature and used as quickly as possible after ripening.
4. During the kitchen's initial tour with the DM, on 2/22/22, at 9:49 a.m., it was observed that Ref 1 had black matter on the door latch. DM stated, the black matter looked like crumbs. It was also observed that Ref 1 had dried dark brown liquid drippings at the back of the inside of the ref 1 wall, the DM stated that it was dried liquid splashes.
5. During a concurrent observation and interview on 2/22/22, at 2:00 p.m., with the DM, a can opener in the kitchen was observed with black matter on it. The DM stated, the black matter was from the can labels that get stuck to the can opener during use. The can opener was also observed with one strand of short white hair stuck on it.
During a review of the facility's cleaning log titled, Daily and Weekly Cleaning Log, dated February 2022, the Daily and Weekly Cleaning Log indicated, the refrigerators and freezers were not cleaned since February 4, 2022.
During a review of the facility's P&P titled, Cleaning Procedure, dated 2014, P&P indicated Light daily cleaning is required for the can opener, hand washing sink, tray card holders, tray cards, steam table wells, refrigerator, coffee makers, range and grill, floor and mats, sink, all scoops, garbage disposer, ovens and milk dispensers.
6. During the initial kitchen tour with the DM, on 2/22/22, at 9:49 a.m., no thermometer was observed in the dry storage room. The DM stated, he could not find the thermometer and he has not checked the temperature in the dry storage area. The DM further stated, a thermometer is needed in the dry storage area room because the temperature for everything (refrigerator, freezer, storage room) should be checked.
During a review of the facility's P&P titled, Storage of Food and Non-Food Supplies, dated 2014, the P&P indicated, 1) Dry storage areas will be equipped with a thermometer.
7. During an observation on 2/22/22, at 9:49 a.m., in the kitchen, the DM was observed not washing hands and changing gloves in between touching the door handle Ref 1 and freezer 1, food items (banana, sliced oranges, sliced turkey pieces) in the refrigerator, freezer and dry storage area, and opening a bag of meatballs and placing it in a pot.
During an observation on 2/22/22, at 11:52 a.m., in the kitchen, the DM and Dietary Staff 1 (DS) were observed not changing gloves and washing hands between touching scoops in the tray line and touching the food cart and refrigerator handles. DS 1 was then observed touching a piece of bread during the tray line with one gloved hand and placed it on two residents lunch plates. It was also observed three times that DM was touching his face mask with his gloved hands without changing it and performing hand hygiene.
During a review of the facility's P&P titled, Hand Washing Policy No. 615, dated 2014, the P&P indicated, When to wash hands: immediately before engaging in food preparation including working with non-repackaged food, clean equipment, utensils and unwrapped single use food containers and utensils; before donning gloves for working with food; during food preparations as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; after engaging in other activities that contaminate hands.
8. During an observation on 2/22/22, at 9:59 a.m., in the kitchen, the DM was observed wearing a hair net that did not cover all his hair inside the hair net and facial hair did not have facial covering.
During an observation on 2/23/22, at 6:59 a.m., in the kitchen, DS 1's hair was not entirely covered with hair net.
During a review of the facility's P&P titled, Personal Hygiene and Appearance Policy No. 210, dated 2014, P&P indicated, All employees must wear hair restraints such as hats, hair coverings or nets that effectively keep hair from contacting with food or clean equipment while working in Dietary department.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observation and interview the facility failed to ensure the proper disposal and refuse of garbage when the trash bin inside the kitchen did not have its lid on for four hours, and the dumpste...
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Based on observation and interview the facility failed to ensure the proper disposal and refuse of garbage when the trash bin inside the kitchen did not have its lid on for four hours, and the dumpster outside the facility was left open.
This deficient practices had the potential to attract rodents and insects and cross-contamination of food.
Findings:
During an observation on 2/22/22, at 9:59 a.m., during the initial tour of the kitchen, a yellow trash bin near the dishwashing area had no lid on it.
During an observation on 2/22/22, at 11:51 a.m., during tray line observation, a yellow trash bin was observed with no lid on it and the trash bin lid was tucked in between the trash bin and the wall.
During an additional observation on 2/22/22, at 2:00 p.m., in the kitchen, the yellow trash bin lid was still observed with no lid on it.
During a concurrent observation and interview on 2/23/22, at 6:59 a.m., with the Dietary Manager (DM), the dumpster outside the facility was observed open and the trash bin inside the kitchen was observed without a lid on it. The DM stated the trash bin and dumpster lids should be kept closed to not attract rodents.
During an interview on 2/24/22, at 9:03 a.m., with the Registered Dietician (RD), the RD stated, trash bin and dumpster lids should be closed, especially, when trash is building up. The RD stated, bacteria could form in the trash bin and dumpster, leading to hazardous food conditions; and it is not sanitary to keep the trash bin and dumpster open. The RD further stated proper disposal of garbage include taking out the garbage when it is three fourths full and having the lids on at all times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A record review of Resident 19's admission Record, dated 2/25/22, indicated Resident 19 was admitted on [DATE].
A record rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A record review of Resident 19's admission Record, dated 2/25/22, indicated Resident 19 was admitted on [DATE].
A record review of Resident 19's Order Summary dated 2/25/22, indicated a Physicians order for a Foley catheter.
During an observation on 2/22/22, at 10:18 a.m., Resident 19's Foley catheter was laying on the floor.
During a concurrent observation and interview on 2/22/22 at 11:01 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 confirmed Resident's 19's Foley catheter bag was laying on the floor. LVN 1 further stated the Foley catheter bag should not be on the floor because it can cause infection.
During an interview on 2/25/22, at 9:40 a.m., with the Director of Nursing (DON), the DON stated the resident's Foley catheter bag should not be on the floor because of risk of infection.
A record review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary (undated), the P&P indicated, be sure the catheter tubing and drainage bag are kept off the floor.
3. A record review of Resident 25's admission Record, dated 2/24/22, indicated Resident 25 was admitted on [DATE].
During an observation on 2/23/22, at 8:09 a.m., RN 1 was observed coming out of a Resident room and proceeded to prepare medications for Resident 25, without performing hand hygiene first.
During an interview on 2/25/22, at 9:40 a.m., with the DON, the DON stated, hand hygiene should be performed before and after administering medications, and between residents to prevent risk of resident infection.
A record review of Resident 16's admission Record, dated 2/24/22, indicated Resident 16 was admitted on [DATE].
During an observation on 2/23/22, at 8:31 a.m., RN 1 was observed dropping her medication cart keys on the floor, then placing it on the medication cart counter. RN 1 did not sanitize her keys or perform hand hygiene after handling her keys that fell on the floor. After RN 1 put her keys on the medication cart counter, RN 1 prepared Resident 16's medications on the medication cart counter. RN 1 did not sanitize the medication cart counter before preparing Resident 16's medications on it.
During an interview on 2/25/22, at 9:40 a.m., with the DON, the DON stated, it is not ok to put medication keys that fell on the floor, on the medication cart counter. The DON stated, it is a risk for resident infection. The DON further stated, keys that fell on the floor should be cleaned first, and hand hygiene should be performed after touching the keys and before preparing medications.
A record review of Resident 27's admission Record, dated 2/24/22, indicated Resident 27 was admitted on [DATE].
During an observation on 2/23/22, at 8:31 a.m., RN 1 prepared Resident 16's medication and placed them on a medication tray. Then RN 1 carried the medication tray inside Resident 16's room and placed it on Resident 16's food tray. After RN 1 administered Resident 16's medication, RN 1 took the medication tray outside the resident room and placed it on the medication cart counter. RN 1 did not sanitize the medication tray before putting it on the medication cart counter. RN 1 proceeded to then prepare medications for Resident 27 on the medication cart counter. RN 1 did not sanitize the medication cart counter before preparing medications for Resident 27.
During an interview on 2/25/22, at 9:40 a.m., with the DON, the DON stated, if a medication tray is taken in a Residents room and placed on a resident's food tray, it should be cleaned with Clorox wipes after because it is a risk for infection.
A record review of the facility's P&P titled, Hand Hygiene, (undated), the P&P indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-anti-microbial) and water for the following situations: . Before preparing or handling medications.
Based on observation, interview, and record review, the facility failed to follow their practices to maintain a clean and sanitary environment to prevent the spread of infections for five of 12 sampled residents (Resident 26, 16, 19, 25, and 27) when:
1. Resident 26 and 19's oxygen tubing was not dated and were observed on the floor and Resident 26's humidifier was not dated,
2. Resident 19's Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) was laying on the floor; and
3. Registered Nurse 1 (RN 1) did not perform hand hygiene before preparing medications for Resident 25, 16, and 27.
These deficient practices had the potential to expose Resident 26, 16, 19, 25, and 27 to possible infection.
Findings:
1. During an observation on 2/22/22, at 11:00 a.m., in Resident 26's room, oxygen tubing was observed on the floor. The oxygen tubing and humidifier (a bottle that puts moisture into the air) were observed not having a date and time when it was changed.
During an interview on 2/23/22, at 10:27 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, it was not ok for oxygen tubing to be touching the floor because it would expose the resident to germs and bacteria, and it could cause a possible infection.
During an interview on 2/24/22, at 9:59 a.m., with the Director of Nursing (DON), the DON stated, it is important to put a date on the oxygen tubing and humidifier so nurses would know when to change the oxygen tubing and humidifier. The DON further stated, if the oxygen tubing and humidifier are used for a long-time, bacteria could grow and open a chance for infection.
During a review of Resident 26's Order Summary Report, dated 2/25/22, the Order Summary Report indicated, to change the humidifier bottle every night shift every three days and to change the nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient or person in need of respiratory help) every Tuesday night shifts.
A record review of Resident 19's Order Summary dated 2/25/22, indicated a physician's order to change the nasal cannula every night shift every 6 days.
During an observation on 2/22/22, at 10:18 a.m., part of Resident 19's oxygen tubing was observed on the floor while Resident 19 was using it. Resident 19's oxygen tubing was not changed for 19 days.
During a concurrent observation and interview on 2/22/22, at 11:01 a.m., with LVN 1, LVN 1 stated, Resident 19's oxygen tubing was labeled on 2/3/22. LVN 1 stated the oxygen tubing should be changed every week or it can cause an infection to the resident. LVN 1 stated the oxygen tubbing should not be on the floor because it can cause infection.
During an interview on 2/25/22, at 9:40 a.m. with DON stated oxygen tubing should not be on the floor and should be changed weekly to prevent infection.
During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy Equipment, (undated), the P&P indicated, It is the policy of this facility to maintain all oxygen therapy equipment in a clean and sanitary manner. The P&P also indicated the mask or cannula should be changed weekly and as needed to keep it free of respiratory secretions and mucus.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility to ensure kitchen equipment was maintained when the dishwasher temperature gauge (a device that measures the dishwasher temperature) did not measure th...
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Based on observation and interview, the facility to ensure kitchen equipment was maintained when the dishwasher temperature gauge (a device that measures the dishwasher temperature) did not measure the correct dishwasher water temperature.
This deficient practice resulted in inaccurate measurements and documentation of dishwasher water temperatures and had the potential for dishes to not be cleaned and sanitized at the recommended temperature.
Findings:
During a concurrent observation and interview on 2/23/22, at 6:59 a.m., with the Dietary Manager (DM), in the kitchen, the dishwasher gauge was observed with the recommended temperature printed on its surface, which indicated 120 degrees Fahrenheit (F, a scale of temperature) minimum. The dishwasher gauge was observed registering water temperatures below the recommended temperature on three separate dishwashing cycles: 100 degrees F on the first cycle, 114 degrees F on the second cycle, and 116 degrees F on the third cycle. The DM stated the temperature of the dishwasher water should be at 120 degrees F.
During an interview on 2/23/22, at 9:53 a.m., with Dietary Staff 1 (DS 1), DS 1 stated, she just finished washing the dishes and took the dishwasher temperatures which measured between 90 degrees F and 110 degrees F.
During a concurrent observation and interview on 2/23/22, at 9:53 a.m., with the DM, the DM was observed test running the dishwasher and the dishwasher gauge was observed registering a temperature of 110 degrees F. The DM was observed manually measuring the dishwasher water with a thermometer and the thermometer indicated 120 degrees F. The DM stated, the dishwasher gauge needs to be calibrated.
During a follow-up observation on 2/23/22, at 2:00 p.m., in the kitchen, with the DM, the DM was observed test running the dishwasher and the dishwasher gauge registered a temperature of 118 degrees F during the test cycle. The DM was observed manually measuring the dishwasher water temperature and the thermometer indicated 122 degrees F.
During an interview on 2/24/22, at 9:03 a.m., with the Registered Dietician (RD), the RD stated, the dishwasher would not properly clean the dishes if the water does not get to the recommended temperature. RD stated, it might cause food borne illness if dishes are not properly cleaned
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt to use alternatives, explain the risk and ben...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to attempt to use alternatives, explain the risk and benefits and obtain informed consent from the resident and resident representative (RR) prior to installment of the bed side rails for 29 out of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25). Also, there was no side-rail assessment conducted prior to initiation of the bed side rails for Resident 30.
The facility's failure to assess bed side rail use for Resident 30 placed Resident 30 at risk for entrapment and injuries. Also, these failures resulted in 29 of 29 residents and their RR's to be unaware of risks and benefits of side rails and to be able to make an informed decision. [cross reference F835]
Findings:
During a record review of the facility's undated document titled, Half side rails list, it indicated all 29 residents residing at the facility had half side rails when in bed as enabler.
During an observation on 2/22/22, at 11:15 a.m. through 2:00 p.m., side rails were up on both sides of the bed for all 29 residents residing at the facility.
During another observation on 2/24/22, between 9:00 a.m. through 2:00 p.m., bilateral bed side rails were up again for all 29 residents.
During a record review of Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25's Side rail utilization assessment-V4,it indicated, three sections: 1. Assessment criteria, 2. Rationale, and 3. Signatures. The assessment did not indicate any section pertaining to explanation of risks and benefits or if residents/ RR agreed to provide an informed consent related to side rail use.
During an interview with the Administrator (ADM ) on 2/24/22, at 12:44 p.m., the ADM stated, the facility did not have any evidence indicating the facility attempted to use alternatives prior to installing bed side rails on all 29 resident's beds. The ADM stated, the only alternative for side rails would be no side rails. The ADM also stated, we don't have the informed consent documented.
During an interview and record review with the Director of Nursing (DON) on 2/25/22, at 12:11 p.m., Resident 1's side rail assessment dated [DATE] was reviewed. Resident 1's assessment had the DON, Activity Director (AD) and Social Services Director (SSD) names on the assessment. The DON stated, the Inter-Disciplinary Team (IDT) names on the assessment indicated which team members discussed side rails use. The assessment also indicated, the RP [Responsible Party] under Responsible Party Signatures. The DON stated, RP meant Resident 1's RR was aware of side rail use and it's risks and benefits. When asked if she talked to Resident 1's RR to discuss side rail use, the DON stated, I haven't talked to anyone recently. The DON stated the IDT was responsible to obtain informed consent for side rail use.
During an interview with the SSD on 2/25/22, at 12:42 p.m., the SSD stated, she was responsible for obtaining care and treatment consent from residents or RR. SSD stated she never obtained an informed consent for side rail use. The SSD further stated, she called all 29 RR's only last night on 2/24/22 to discuss the use of side rails and to obtain informed consents.
During an interview with RR 1 on 2/25/22, at 1:18 p.m., RR 1 stated, the facility obtained a written informed consent for side rail use only that day (2/25/22). RR 1 further stated, the facility did not explain the risks and benefits of side rails use prior to 2/25/22.
During an interview with the DON on 2/24/22, at 10:07 a.m., the DON stated, she was aware the facility needed to obtain an informed consent for side rails from the resident or RR because it could be considered a restraint. The DON stated the facility did not have documentation indicating if risks and benefits for side rail use were explained to residents and/or RR to choose or decline side rails.
During a concurrent observation and interview with Registered Nurse (RN 1) on 2/24/22, at 9:58 a.m., Resident 30's bed was observed with half side rails up on both sides. RN 1 stated Resident 30's bed always had half side rail up because Resident 30 always tried to get out of bed.
During an interview and record review with the Director of Nursing (DON) on 2/24/22, at 10:22 a.m., the DON was unable to locate a side rail assessment and stated, the facility did not complete the side rail utilization assessment for Resident 30. The DON stated the facility placed bedside rails on all 29 residents' beds since their date of admission. The DON further stated, Resident 30 was placed on side rails since her admission date on 1/24/22.
During a concurrent interview and record review with the Activity Director (AD) on 2/25/22, at 11:54 a.m., Resident 30's side rail assessment dated [DATE] was reviewed. The assessment indicated the AD, Social Services Director (SSD) and DON's names under the signatures section in the side rail assessment for Resident 30. The AD stated, she was not aware and involved in Resident 30's side rail assessment. The AD stated, she was not aware of any risks related to side rail usage. The AD further stated, she did not recall facility staff discuss the use, risks, and benefits of side rails with residents/ families.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility's administration failed to identify, update and implement it's outdated policy and procedure for bed side rail use. The facility failed...
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Based on observation, interview, and record review, the facility's administration failed to identify, update and implement it's outdated policy and procedure for bed side rail use. The facility failed to administer bed side rails without reviewing risks and benefits; obtaining an informed consent from residents/ resident representatives; and without using less restrictive alternatives prior to installing bed side rails to 29 of 29 residents (Resident 17, 13, 3, 8, 9, 27, 2, 20, 24, 29, 15, 30, 6, 1, 7, 14, 19, 22, 18, 23, 31, 26, 28, 21, 5, 11, 10, 16, and 25) residing at the facility.
This failure placed all 29 residents residing at the facility at risk for avoidable injuries.
[cross reference F700]
Findings:
During a record review of the facility's undated document titled, Half side rails list, it indicated all 29 residents residing at the facility had half side rails when in bed as enabler.
During an observation on 2/22/22, at 11:15 a.m., bed side rails were up on both sides of the bed for all 29 residents residing at the facility.
During another observation on 2/24/22, at 9:00 a.m., bilateral (both sides) bed side rails were up again for all 29 residents.
During an interview with the Director of Nursing (DON) on 2/24/22, at 10:17 a.m., the DON stated, the facility did not have documented informed consent for bed side rail use for all 29 residents residing at the facility. The DON stated, If we have to, we can create the consent.
During an interview with the ADM on 2/24/22, at 12:44 p.m., the ADM stated, the facility did not have any evidence indicating the facility attempted to use alternatives prior to installing bed side rails on all 29 resident's beds. The ADM stated, the only alternative for side rails would be no side rails.
During an interview and record review with the Assistant Administrator (AADM), on 02/24/22, at 11:11 a.m., the facility's (P&P) titled, Health Information Management Policy and Procedure Manual Approval Sheet was reviewed. The P&P indicated three columns: Review/Revision Date, Approval Date, and Approved by. Nine staff, including the Administrator (ADM), DON, Social Services Director (SSD) and Activities Director (AD) signed their names on the Approved by column and dated it 5/19/21 on the Approval Date column. The AADM stated, the facility reviewed and revised its P&P on an annual basis and the most recent P&P review and revision was conducted on 5/19/21.
During a record review with the ADM on 2/24/22, at 12:44 p.m., the State Operations Manual Appendix PP (a manual that contains the primary survey and certification rules and guidance from the Centers for Medicare and Medicaid Services), revised on 11/22/17 was reviewed. Under F700 (a regulatory tag), it indicated, The facility must attempt to use appropriate alternatives prior to installing a side or bed rail . Assess the resident for risk of entrapment from bed rails prior to installation .Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.
During a concurrent interview and record review with the Administrator (ADM), on 2/24/22, at 12:44 p.m., the facility's undated P&P titled, Siderails as enabler was reviewed. The ADM stated, he was a part of the policy review team back in 2021, however, the facility's current bed side rails P&P was not updated since 2017. The ADM further stated, the facility's P&P did not reflect the current requirements to explain the risks and benefits and to obtain an informed consent from residents or RPs prior to placing the bed side rails on residents' beds.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide one of one sampled resident in room [ROOM NUMBER] with at lea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide one of one sampled resident in room [ROOM NUMBER] with at least 80 square feet per resident.
This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside.
After observation and interview, there was adequate space for the resident and staff to move about without obstruction. Recommend granting waiver.
Findings:
During a concurrent observation and interview, on 2/24/22 at 11:30 a.m., with the Administrator (ADM), room [ROOM NUMBER] was observed with two beds. The room measured 181.5 inches by 121 inches, with a total of 152.5 square feet. The ADM stated the room is below the standard of 80 square feet per resident and a double occupancy room should measure 160 square feet.
There were no negative consequences attributable to the decreased space in room [ROOM NUMBER]; nor were any safety concerns noted.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most California facilities.
- • 41% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 30 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Bancroft Healthcare Center's CMS Rating?
CMS assigns BANCROFT HEALTHCARE CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Bancroft Healthcare Center Staffed?
CMS rates BANCROFT HEALTHCARE CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 41%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Bancroft Healthcare Center?
State health inspectors documented 30 deficiencies at BANCROFT HEALTHCARE CENTER during 2022 to 2025. These included: 1 that caused actual resident harm, 27 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Bancroft Healthcare Center?
BANCROFT HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 39 certified beds and approximately 35 residents (about 90% occupancy), it is a smaller facility located in SAN LEANDRO, California.
How Does Bancroft Healthcare Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, BANCROFT HEALTHCARE CENTER's overall rating (4 stars) is above the state average of 3.2, staff turnover (41%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Bancroft Healthcare Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Bancroft Healthcare Center Safe?
Based on CMS inspection data, BANCROFT HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Bancroft Healthcare Center Stick Around?
BANCROFT HEALTHCARE CENTER has a staff turnover rate of 41%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Bancroft Healthcare Center Ever Fined?
BANCROFT HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Bancroft Healthcare Center on Any Federal Watch List?
BANCROFT HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.