Elk Grove Post Acute

In the surveyor’s words

From the most serious findings on record at Elk Grove Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 13, 2024

  Based on interview and record review, the facility failed to implement measures to prevent an avoidable fall for one of four sampled residents (Resident 1) when she was transferred from her bed to a chair without the use of a mechanical lift. This failure resulted in Resident 1 sustaining a left distal femur (lower end of thigh bone) fracture. Findings: A review of Resident 1's admission record indicated she was admitted in August of 2014 with diagnoses including hemiplegia and hemiparesis (weakness and paralysis of the body) affecting the right dominant side and dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgement). […]

• Actual harm, isolatedF689Dec 22, 2023

  Based on interview and record review, the facility failed to provide the required two-person staff participation to use the toilet for one of three sampled residents (Resident 1), when Resident 1 was left alone while on the toilet, fell , and hit her head. This failure resulted in Resident 1 spending five days in the hospital to receive treatment for an acquired subdural hemorrhage (a severe and sudden loss of blood from a damaged blood vessel in the brain). Findings: A review of Resident 1's admission record indicated admission to the facility on [DATE], with diagnoses which included a displaced right femur (thigh bone) fracture after a fall, Parkinson's disease (a degenerative brain condition which results in problems with balance and movement) with dyskinesia (involuntary and erratic… […]

• Actual harm, isolatedF689Nov 17, 2023

  Based on interview and record review the facility failed to provide adequate supervision and assistance for one of four sampled residents (Resident 1) when Resident 1 who required two-person assistance for bed mobility as per the Minimum Data Set (MDS, an assessment tool) fell from the bed while being assisted by one staff instead of two during incontinent care. Additionally, the one staff who was assisting the Resident turned away from her to grab a garbage bag on the floor. This failure resulted in Resident 1 sustaining a laceration (a deep cut or tear) on her left forehead, a left midclavicular (the bone connecting the breastbone and shoulder) fracture, and a left rib fracture. […]

• No harm, potential for more than minimal, widespreadF755Feb 16, 2024

  Based on observation, interview, and record review, the facility failed to provide accurate and safe pharmaceutical services to meet the needs of 22 residents for a census of 124, when: 1. Licensed Nurses (LN 6 and LN 3) administered residents' medications scheduled for 9 a.m., more than an hour later than the scheduled time; 2. Resident 153 missed her morning dose of medication to treat restless leg syndrome (involuntary leg movement which causes uncomfortable sensation in legs) and 3. Resident 203's pain medication was not signed as given in a timely manner. These failures had the potential for ineffective medication therapy. Findings: During a concurrent observation and interview on 2/13/24 at 10:28 a.m., LN 6 was observed passing medications in North East Hall. […]

• No harm, potential for more than minimal, widespreadF804Feb 16, 2024

  Based on observation, interview and record review, the facility failed to ensure food was served with an appetizing temperature for 8 out of 31 sampled residents (Resident 34, Resident 88, Resident 1, Resident 403, Resident 10, Resident 49, Resident 43 and Resident 37). This failure had the potential for the residents not consuming their meals and may cause weight loss. Findings: During an interview on 2/13/24 at 9:15 a.m. with Resident 34, Resident 34 stated, food is unacceptable, the temperature was cold. During an interview on 2/13/24 at 10:23 a.m. with Resident 88, Resident 88 stated, food is sometimes cold. During an interview on 2/13/24 at 10:30 a.m. […]