Inspection Reports for
Fonda Specialty Care

One complaint was investigated as part of the survey. The complaint involved issues with blood sugar monitoring and physician notification for a resident. The complaint was substantiated as evidenced by cited deficiencies.

Deficiencies were cited related to failure to meet professional standards of care for 1 of 5 residents, inadequate supervision to prevent falls for 1 of 3 residents, improper storage of respiratory supplies for 2 residents, and failure to ensure proper medication storage and administration including insulin pen handling. The facility also failed to maintain an effective water management plan for Legionella risks.

Complaint #118015-C was substantiated. Complaint #119293-C was not substantiated. Self-report #119878-I was not substantiated.

The facility failed to ensure residents received medications per physician orders, specifically for Resident #1, resulting in medication administration errors and delays in pharmacy ordering and receiving medications. The complaint #118015-C was substantiated, while complaint #119293-C and self-report #119878-I were not substantiated.

The complaint investigation found substantiated issues with medication administration and pharmaceutical services for Resident #1, including missed doses and medication unavailability.

The facility failed to ensure one resident received all prescribed medications timely, including Tamiflu and pain medications, and failed to provide nebulizer treatments as ordered. The facility reported medication shortages and delays in obtaining medications from the pharmacy.

Complaint #117429-I was substantiated. The facility failed to notify the physician and family of a resident's significant change in condition and failed to provide adequate pain management and assessment.

The facility was found to have failed to notify the physician and family of a significant change in condition for one resident, including increased pain and a sternal wound. The resident experienced inadequate pain management and lack of timely assessment and intervention, resulting in a substantiated deficiency related to quality of care and notification of changes.

The complaint involved failure to notify the physician and family of Resident #1's increased pain and change in condition. The complaint was substantiated with findings of inadequate pain management and communication.

The facility failed to notify the physician and family of Resident #1's increased pain and change in condition. The resident experienced severe pain with inadequate relief and cognitive decline, but staff did not provide timely interventions or notify the physician as required by policy.

Complaint #116718-C was substantiated.

The facility failed to maintain a home-like environment due to a strong offensive urine odor throughout the facility, failed to communicate necessary information during an emergency hospital transfer, failed to accurately complete assessments, failed to develop and update baseline and comprehensive care plans appropriately, failed to meet professional standards for catheter orders, failed to provide appropriate incontinence care, and failed to maintain proper infection prevention and control practices including hand hygiene.

The facility was found deficient in multiple areas including failure to maintain a home-like environment due to offensive urine odor, inadequate communication during resident transfers, inaccurate resident assessments, incomplete care plans, lack of physician orders for catheter care, improper incontinence care, and failure to follow infection prevention protocols.

The facility failed to provide appropriate incontinence care for one of two residents reviewed, specifically Resident #27, as staff did not cleanse all required areas during perineal care and did not fully comply with facility policy on glove changes and hand hygiene.

Complaints #113175, #112685, #112628, and #112616 were substantiated following investigation from August 1 to August 8, 2023.

The facility failed to maintain accurate and complete records of controlled substances, including lack of staff signatures on narcotic counts and inconsistent reconciliation of medications. Multiple discrepancies were found in narcotic counts for medication carts and individual residents, indicating poor compliance with pharmacy service procedures.

The investigation was complaint-related, focusing on narcotic count discrepancies and medication record inaccuracies. The complaint was substantiated with findings of missing narcotic counts and undocumented medication administration.

The facility failed to ensure drug records were accurate and did not consistently reconcile controlled medications across multiple medication carts and the medication room. Several narcotic counts were missing or inaccurate, with documented discrepancies involving specific residents' medication records and staff failure to properly document administration and counts.

The complaint #111171-C was substantiated. The investigation included review of multiple complaints (#108529-C, #108838-C, #108860-C, #109201-C, #109263-C, #110210-C, #110798-C, #111030-C, #111171-C, #111173-C) and facility-reported incidents (#108385-I and #111450-I) conducted from February 23, 2023 to March 8, 2023.

The facility failed to ensure that a resident requiring respiratory care, including tracheostomy suctioning, received care consistent with professional standards. Specifically, the facility did not provide required suctioning for Resident #2, leading to respiratory distress and ultimately the resident's death. Staff interviews confirmed the resident's need for suctioning and availability of suction equipment, but suctioning was not performed timely.

The investigation was complaint-driven, focusing on Resident #2's respiratory care needs. The complaint was substantiated as staff failed to suction the resident despite clear indications and available equipment, leading to the resident's death.

The facility failed to provide necessary suctioning to Resident #2 who indicated respiratory distress by patting/pointing at his stoma. Despite multiple staff confirmations that the resident needed suctioning and the availability of suction equipment, the resident did not receive timely suctioning and subsequently died. Interviews with staff and the primary care provider confirmed the failure to suction as required.

The facility had multiple deficiencies including failure to complete timely admission assessments, incomplete care plans, inadequate bathing assistance, failure to provide ordered treatments, lack of RN coverage for certain days, improper psychotropic medication orders, food served at unsafe temperatures, improper food handling, infection control breaches during a COVID-19 outbreak, and failure to offer required vaccinations.

Complaints #107528-C and #108394-C were substantiated. Complaint #107895-C was not substantiated.

The facility failed to complete a comprehensive admission assessment within 14 days for one resident, failed to develop a complete baseline care plan for a new admission, failed to provide adequate bathing assistance for dependent residents, failed to provide treatments and care as ordered by physicians, failed to ensure proper food temperatures and food safety, failed to maintain infection prevention and control practices, and failed to ensure proper documentation and administration of psychotropic medications. The facility also had deficiencies related to resident transfer supervision and COVID-19 infection control.

The inspection resulted from investigation of complaints #100324-C (unsubstantiated), #102967-C (substantiated), #102969-C (unsubstantiated), #103169-C (unsubstantiated), #104416-C (unsubstantiated), #104741-C (unsubstantiated), #104455-C (substantiated), #104709-C (substantiated), #105398-C (substantiated), and facility reported incidents #100951-I (unsubstantiated), #103320-I (unsubstantiated).

The facility was found to have deficiencies related to reasonable accommodations, safe and clean environment, professional standards, ADL care, increase/prevent decrease in range of motion, medication errors, and infection prevention and control. Several residents were affected, and staff were re-educated on various protocols.

The complaint investigation was related to an elopement incident involving Resident #1. The self-report #97594-I was substantiated, while complaint #98828-C was not substantiated.

The facility failed to adequately supervise residents at risk for elopement, specifically Resident #1 who eloped from the building on 6/13/21. The care plan did not identify or have sufficient interventions to prevent elopement. The resident was found outside the facility after removing an air conditioner from a window and leaving the building. The facility implemented corrective actions including securing windows and door alarms.

The facility was found deficient in ensuring residents' rights to dignity and respect, specifically related to staff speaking Spanish while providing care, which made some residents uncomfortable. The facility planned corrective actions including staff education and monitoring.