California Park Post Acute

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident's right to self administer medications was maintained in accordance with facility policy for one of three sampled resident (Resident 1). The facility did not assess, determine, or document through the interdisciplinary team (IDT, a group of healthcare professionals who work together to assess, plan, and manage the medical, functional, and social needs of a resident) that Resident 1 was clinically appropriate to self administer medications. This resulted in medications being left at Resident 1's bedside, creating the potential for misuse, missed doses, or adverse drug outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure one Certified Nursing Assistant (CNA A) had appropriate competency and skill sets to care for residents based on their identified needs. This failure had the potential to place residents' safety at risk.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a certified nursing assistant (CNA) immediately reported an allegation of rough care to facility management so they could carry out the facility's abuse protocol for 1 (Resident #32) of 1 resident reviewed for an allegation of staff-to-resident abuse.

Inspectors wroteBased on interview, record review, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the classes of medications received during the assessment look-back periods for 2 (Resident #74 and Resident #70) of 2 residents reviewed as part of the Resident Assessment task and failed to ensure MDS assessments accurately reflected weight-loss statuses for 2 (Resident #8 and Resident #25) of 2 sampled residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 2 sampled residents (Resident 2) was treated with dignity and respect during direct patient care when privacy was not provided, and Resident 2 was rushed. This failure resulted in Resident 2 feeling embarrassed, with increased anxiety, and difficulty sleeping.

Inspectors wroteBased on interview and record review, the facility failed to ensure the licensed nurses reported changes of condition to the physician for 1 of 3 residents (Resident 1) when: 1. Resident 1 had edema (swelling) that went from mild lower leg edema to deep pitting (leaves an indent in skin for a period of time) to the hips. This resulted in a transfer to hospital for fluid overload, ascites (fluid in abdomen), anasarca (fluid throughout all of body, puffy body), bilateral pleural effusions (fluid in the lungs), and exacerbated (make worse) his congestive heart failure. 2. Resident 1 had sudden new onset of 7/10 pain (severe pain) with as needed (PRN) pain medication given for first time on 8/18/24 and 8/19/24. This resulted in increased pain and discomfort.

Inspectors wroteBased on interview and record review the facility failed to ensure licensed nursing staff had the skills and competencies to ensure the medical needs for one of three sampled residents (Resident 1) were met when significant changes of condition were not identified and reported to the physician. This resulted Resident 1 to be transferred to the hospital for fluid overload, ascites (fluid in abdomen), anasarca (fluid throughout all of body, puffy body), bilateral pleural effusions (fluid in the lungs), and exacerbated (make worse) congestive heart failure.

Inspectors wroteBased on interview and record review, this requirement was not met when the facility failed to provide pain medication as ordered to one of five sampled residents (Resident 1). This caused Resident 1 to have significant back pain, interrupted his sleeping patterns, and had the potential to negatively affect his health. Findings A review of Resident 1's admission Record, dated 1/12/24, indicated he was admitted to the facility after being hospitalized for pneumonia (an infection of the lungs), and he had a history of back pain. [...]

Inspectors wroteBased on interview and record review, this requirement was not met when the facility failed to be free of significant medication errors when a necessary heart medication was not provided to one of five sampled residents (Resident 1) after it was ordered by a physician. This had the potential to put Resident 1 at risk of heart failure, further hospitalization, or death. Findings Resident 1 was admitted to the facility after being hospitalized for pneumonia, and severe peripheral artery disease following a history of heart surgery. During his hospitalization, he was diagnosed with atrial fibrillation (Afib, a heart condition that causes the heart chambers to be chaotically and out of rhythm, dysrhythmia) and he was prescribed digoxin, an important medicine to correct this dysrhythmia, to be continued by the long-term care facility. [...]

Inspectors wroteBased on interview and nursing schedule review, the facility failed to ensure that there was a Registered Nurse (RN) on duty 8 hours per day/ 7 days a week. This failure had the potential to adversely affect oversight and direction regarding resident's quality of care and quality of life directly impacting overall health and well-being.

Inspectors wroteBased on interview and record review, the facility did not report a failed water heater to state and local agencies for 12 days. This failure had the potential to place all residents at risk for exposure to germs and illness related to a lack of hot water.

Inspectors wroteBased on interviews, observations and record review the facility failed to ensure essential equipment was maintained in safe working order when: 1. The temperature of the nourishment refrigerator located in nursing station one was above 41 degrees Fahrenheit (° F, a unit of measuring temperature). 2. The manufacturer guidelines were not followed for cleaning and sanitizing the ice machine. 3. A walk-in freezer located in the large storeroom in the basement had ice build-up on the inside of the door, around the fans and around a pipe. These failures had the potential for the equipment to not be maintained to ensure proper functioning.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that care plans for three of 17 sampled residents (Resident 25, 62, and Resident 275) were revised and updated to identify resident specific needs. This failure had the potential for residents individual care needs to go unrecognized, and a risk for a decline in residents physical, mental, and psychological status related to weight loss, communication needs, and proper transfers required to for pain management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe handling of prescription medications with census of 66, based on standards of practice and regulatory requirements when: 1. The Emergency Kit (or EKit, an emergency supply of drugs that used based on a doctor order for urgent needs of a resident) for injectable (or a shot) drugs was not safely secured after use and was not replaced on timely manner in the main medication room. 2. The disposition of discontinued or unusable prescription medications were not cosigned by two licensed staff in both medication rooms. These unsafe medication handling practices could contribute to risk of diversion (abuse of prescription drugs) and drug loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication administration practices when medication error rate was more than 5% (% or percentage- number or ratio that expressed as a fraction of 100) with the census of 66 residents. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of five errors out of 38 opportunities which resulted in a facility wide medication error rate of 13.16 % in two out of nine residents (Resident 8 and Resident 15) during medication administration observation. These failures may result in unsafe medications use, medication error, and not following the doctor's orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe medication storage practices in three out of five medication and treatment Carts (cart or container on a wheel that stored immediate use medications) with census of 66 residents when medications were not marked with beyond use date (the date a product should no longer be used) based on manufacturer recommendations. These failed practices may result in unsafe and spoiled medication use in the facility.

Inspectors wroteBased on observation, and interview, the facility failed to ensure federal regulations related to the education qualification requirements of the dietary manager were followed as outlined in the California Code, Health and Safety Code (HSC 1265.4). This failure had the potential to result in inadequate oversight of the food and nutrition services department associated with meal distribution accuracy, safe food handling and sanitation guidelines.

Inspectors wroteBased on observation, interview, facility document and Policy and Procedure review, the facility failed to ensure Food and Nutrition Services followed food safety and sanitation guidelines when: 1. Two of two hand washing sinks didn't not reach 85 degrees Farenheight (° F, a unit of measuring temperature). 2. The temperature in the nourishment refrigerator located on Nursing Station 1 was 4° F above the recommended temperature range. 3. The ice machine located in kitchen was not clean. 4. The sanitizer solution in the third compartment of the manual dishwashing sink was less than 200 parts per million. 5. Time temperature control for safety foods (TCS) prepared at ambient temperature (room temperature) were not monitored on the cool down log. 6. Food preparation equipment was not air dried. 7. Food service utensils were not in sanitary condition. 8. [...]

Inspectors wroteBased on interviews, observations and record review the facility failed to ensure the policy for resident food brought from the outside allowed food to be reheated. In addition, family members, and visitors who brought food from the outside were not informed of safe food handling practices, and employees were not educated on safe food handling practices. This failure had the potential for food brought in from the outside to not be handled in a safe manner.

Inspectors wroteBased on observation, interview, Policy and Procedure review, the facility failed to ensure refuse was stored in a sanitary manner when: One of three outdoor refuse dumpsters was not closed, and the surrounding area was not maintained in a sanitary manner. This failure had the potential to attract vermin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of seventeen residents, (Resident 43 and Resident 276) were monitored and the physician updated for a change in condition. 1. Resident 43's physician was not updated with a new onset of cough, and inablity to sleep due to new cough for at least 4 days. 2. Resident 276's physician was not updated with Urinalysis (U/A, a test to diagnose a urinary tract infection (UTI) results from 10/16/23, and Culture and Sensitivity (a test to identify specific antibiotics for treatment of a UTI) results for three days. Resident 276 was not monitored for signs and symptoms of an infection during pending U/A results which indicated Resident 276 did have a UTI. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete the Comprehensive Minimum Data Set (MDS, a standardized resident assessment) within 14 calendar days of admission for two of 17 sampled residents (Resident 275 and Resident 276.) This failure had the potential to delay the development of a comprehensive care plan necessary to provide appropriate individualized care and services for each resident related to the care areas that would have been identified on the Comprehensive MDS.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a comprehensive care plan for one of 17 residents (Resident 53). This resulted in Resident 53 did not have a care plan to address her fluid restriction.

Inspectors wroteBased on observation, interview, medical record review, and facility Policy and Procedure review, the facility failed to ensure one of 17 final sampled residents (Resident 25) maintained acceptable parameters of nutritional status when: 1. The facility failed to provide documentation which showed the physician was notified of Resident 25's unplanned severe weight loss of 9.2 pounds, 7.2% from 9/11/23 to 9/30/23, and 13 pounds, 10% unplanned severe weight loss from 9/11/23 to 10/6/23, 2. The facility failed to reweigh Resident 25 per the facility policy when he experienced a severe weight loss of 9.2 pounds, 7.2% from 9/11/23 to 9/30/23, and 13 pounds, 10% severe weight loss from 9/11/23 to 10/6/23. 3. [...]

Inspectors wroteBased on observation, interviews and facility document review, the facility failed to ensure the menu was followed for 2 of 18 residents who received a controlled carbohydrate diet (CCHO, a diet that contains carbohydrate rich foods in fairly equal amounts) for Residents 52 and 272. This failure had the potential to result in the resident to not receive the CCHO diet as planned.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure and maintain infection control practices with census of 66 when: 1. The facility failed to ensure safe cleaning and sanitization of the shared glucometer (medical device used to measure blood sugar from a drop of blood) when the glucometer was not disinfected on three out of three residents (Residents 12, Resident 31, and Resident 273) tested for blood sugar level, based on standards of practice and manufacturer recommendations. 2. The facility failed to maintain infection control practices when one Housekeeping Staff (HSK A) failed to keep a clean sheet off the floor. These failures had the potential to cause the spread of germs which could have placed the vulnerable resident population at risk for infection and illness.

Inspectors wroteBased on interview, policy, and clinical record review, the facility failed to revise 1 of 1 sampled resident's (Resident 32) Physician Orders for Life Sustaining Treatment (POLST, a directive that specifies what services and treatment an individual wishes in the event of an emergency or code blue such as resuscitation (CPR), hospitalization, artificial hydration and tube feedings). This had the potential for Resident 32 to receive end of life services and treatment that were against her wishes and negatively impact her quality of life.

Inspectors wroteBased on observation, interview, clinical record and policy review, the facility failed to ensure that their restraint policy was followed for 1 of 2 sampled residents (Resident 32), when a bed alarm and wheelchair alarm was initiated for Resident 32 without informed consent (information given to the resident or responsible party (RP) about the restraints and verification that they agreed to using them), a pre-restraint evaluation (a determination that the restraint is necessary before initiating), a specific diagnosis (medical reason), or reviewed by the Interdisciplinary Team (IDT, a team of health care professionals who work in a coordinated fashion toward a common goal for the patient) within 72 hours after initiation. This resulted in an unnecessary alarm restraint used on Resident 32, when there was no assessment or consent for the restraint alarm.

Inspectors wroteBased on interview and clinical record review, the facility failed to develop comprehensive care plans for 3 of 16 sampled residents. Two residents (Residents 32 and 213) were taking psychotherapeutic medications (a medication that affects the mind, emotions and behavior) and 1 resident (Resident 313) was on hospice care (supportive care to terminally ill residents that focuses on their comfort, quality of life, and being pain free). 1. Resident 32 did not have a care plan developed for the use of Ativan (an anti-anxiety psychotherapeutic medication that affects the mind, emotions and behavior). 2. Resident 213 did not have a care plan developed for the use of Seroquel (an antipsychotic psychotherapeutic medication). 3. Resident 313 did not have a care plan developed for Hospice (care that focuses on the end of life wishes of the terminally ill). [...]

Inspectors wroteBased on interview, clinical record, and policy review, the facility failed to ensure that the consultant pharmacist (CP) A identified an irregularity in the Medication Regimen Review (MRR), for 1 of 1 sampled resident who was taking Ativan (an anti-anxiety psychotherapeutic medication- medication that affects the mind, emotions and behavior), and the facility had incorrectly monitored for the adverse side effects of an antidepressant medication. (Resident 32) This had the potential for unwanted adverse side effects to go unrecognized and impair the Resident 32's quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that their medication error rate did not exceed 5 percent or greater for two of seven sampled residents (Resident 51 and 15) when three medication errors were observed within 32 opportunities when: 1. Resident 51 had two medications administered without following manufacturer's instructions. 2. Resident 15 was administered an inhaler without following manufacturer's instructions. This failure resulted in the facility's medication error rate to be 9.38 percent and had the potential medication to be ineffective for all residents.