Pacific Coast Manor

Inspectors wroteDuring a review of Resident 1's MD (medical doctor) Progress note dated 1/23/25, note indicated, Pt [patient] admitted for fall at home. Assessment/Plan.10. OSA (obstructive sleep apnea) G47.33 [diagnosis code] Continue home CPAP. During a review of Resident 1's Order Summary Report dated 3/25/25 at 10:40 am, current orders indicated, no active orders for the use of a CPAP machine. During a review of Resident 1's Medication Administration Record (MAR) dated 1/21/25-2/28/25, MAR indicated no administrations charted for the use of a CPAP machine for any day. During an observation on 3/25/25, at 10:40 a.m., in Resident 1's room, no CPAP machine was observed in the room. During a review of Resident 1's Facesheet, dated 3/25/25, facesheet indicated Resident 1 had a diagnosis listed for Obstructive Sleep Apnea (Adult).onset date 12/20/24. [...]

Inspectors wroteBased on interview, record reviews, and facility policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I Screening was updated to reflect the presence of newly diagnosed serious mental disorders for 1 (Resident #67) of 3 residents reviewed for PASARR requirements.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were securely stored for a resident deemed safe to self-administer medications for 1 (Resident #247) of 1 resident reviewed for secure storage of self-administered medications.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) to notify the Office of State Long-Term Care Ombudsman (organization that advocates for the residents) when one of two sample resident (Resident 1) was transferred to the acute care hospital (ACH: provides treatment for brief but severe episode of illness and conditions) from the facility. This failure had the potential to compromise Resident 1's admission, transfer, and discharge rights.

Inspectors wroteBased on interview and record review the facility failed to ensure to follow their policy and procedure (P&P) to assess for history of psychosocial, trauma and stressors trigger an event, for two of two sample residents (Resident 1 and 2). This failure had the potential to effect health, psychosocial well-being, and person-centered trauma informed care for Resident 1 and 2.

Inspectors wroteBased on interview and record review, the facility failed to protect resident's right to be free from physical abuse for two of two sampled residents (Resident 1 & Resident 2) when: 1. Resident 1 was hit in the face by Resident 3 2. Resident 2 was kicked in the leg by Resident 3. These failures resulted in Resident 1 sustaining a minor laceration to the face and Resident 2 sustaining a minor laceration to the leg, both requiring minor medical care.

Inspectors wroteBased on interview and record review, the facility failed to protect a resident's right to be free from sexual abuse for one of two sampled residents (Resident 1) when Certified Nursing Assistant (CNA A) observed kissing Resident 1 on the face. This failure had the potential to endure emotional and psychological harm for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure social services advocating and assisting residents to promote resident's rights for one of three residents (Resident 1) and significant family members (SFM). This failure had the potential to result in the Resident 1 for not receiving necessary mental, psychosocial, emotional support, care, and services to attain Resident 1's highest practicable well-being.

Inspectors wroteBased on interview and document review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis based on Staffing Data Report submitted to Centers for Medicare & Medicaid Services (CMS). This failure had the potential to affect resident's care, health, and psychosocial wellbeing.

Inspectors wrote2. During an observation on 6/13/2023 at 9:38 AM, in Resident 37's room, CNA H applied Resident 37's Foley catheter's dignity bag with both gloved hands. However, after leaving the resident's room, the CNA H disposed of her gloves in the trash bin located in the hallway without performing hand hygiene immediately. The CNA H proceeded to open the storage closet in the hallway, removed linens, and then returned to Resident 37's room. CNA H did not perform hand hygiene promptly after disposing of her gloves and handling the linens in the hallway. During an interview on 6/13/2023 at 1:44 p.m., with CNA H, she acknowledged the observation and stated she should have performed hand hygiene after disposing of her gloves. During an interview on 6/16/2023 at 4:00 p.m., with the Infection Preventionist (IP), IP stated hand hygiene should have been performed between tasks and after removing gloves. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight residents (59) had informed consent (written permission before implementing a healthcare intervention) prior to initiating a change in dosage of psychotropic medication (medication capable of affecting the mind, emotions, and behavior). This failure resulted in the resident receiving psychotropic medication without being informed about the change in dosage, the risks and side effects.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, a comprehensive assessment tool) discharge assessment in a timely manner for two of five residents (Residents 69 and 23). This failure resulted in the resident's discharge assessment not being transmitted and received by the Center for Medicare and Medicaid System (CMS) within the time requirement.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the PASRR (pre-admission screening and resident review, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) for one of two residents (Resident 3). This failure had the potential to put the resident at risk for not receiving appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards for one of 22 sampled selected residents (Resident 6) when Licensed Vocational Nurse G (LVN G) did not wait for the recommended time between each puff of the inhaler medications. This deficient practice had the potential for Resident 6 to not receive the full amount of each medication and the adverse effects on resident's health.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of accidents and hazards for two of 22 sampled residents (39 and 145) when: 1. Resident 39's smoking safety was not reviewed quarterly and the smoking care plan was not followed; and 2. Resident 145 was not properly assessed for Smoking Safety Screen. These failures had the potential to result in serious injury to the residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review the risks and benefits of bed rails (adjustable metal or rigid plastic bars that attach to the bed) for three of 22 sampled residents (Residents 81, 72 and 53). This failure had the potential to put the residents at risk for entrapment and serious injury due to not being aware of the risks and benefits of bed rails.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) reconciled with the corresponding Medication Administration Records (MAR) for two of 3 randomly selected residents (Residents 53 and 13). This deficient practice had the potential to result in medication error and/or drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure three of 8 sampled residents (Residents 57, 63, and 59) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when: 1. Resident 57 received Seroquel (used to treat certain mental or mood conditions) without an appropriate diagnosis and monitoring behavior, as recommended by the Pharmacy Consultant (PC); 2. Resident 57 received PRN (as needed) Lorazepam (medication used to treat anxiety) beyond 14 days and without supportive rationale for its continued use; 3. Resident 63 received prn (as needed) Temazepam (used to treat insomnia (difficulty falling asleep or staying asleep) without monitoring hours of sleep; and 4. Resident 59 received Lorazepam without documentation of its specific duration in the resident's clinical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately label a Tuberculin (TB, aid in the detection of infection with Mycobacterium tuberculosis) vial for 1 of 2 medication rooms observed. This deficient practice had the potential to affect residents' health and well-being in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage when food brought by visitors to one of 22 residents (Resident 46) was not properly stored. This failure had the potential to result in food-borne illness and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct regular inspections of resident bed frames for one of 22 beds. The facility failed to ensure the footboard was securely, properly installed, and maintained according to the manufacturer's requirements. This failure had the potential to place the residents at risk for accidents and unsafe environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights (a device to call help when needed) were within residents' reach and answered in timely manner for seven of 18 residents (Residents 2, 8, 9, 27, 32, 46, and 231). This failure placed residents at risk for unmet needs and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided meet professional standards for two of five residents reviewed, when Resident 286's multivitamins with minerals was not given and Resident 23's vital signs (VS, clinical measurements, specifically pulse rate, temperature, respiration and blood pressure) were not monitored as ordered, which had the potential to result in compromising residents' health conditions.

Inspectors wroteBased on interview and record review, the facility failed to monitor wound progress for one of four residents when there was lack of wound assessments that included Braden scale (for predicting pressure ulcer risk) and description of skin condition or wound measurement for the period of 10/20/19 to 11/15/19, which had resulted in Resident 52's Stage 2 pressure ulcer (partial thickness skin loss involving the epidermis) on the coccyx (tailbone).

Inspectors wroteBased on interview and record, review the facility failed to ensure two of 18 residents (Residents 47 and 72) were free from unnecessary drugs when there was no evidence of documentation that the the side effects for the use of psychotropic medications (medications capable of affecting the mind, emotions, and behavior) was monitored. This failure had the potential for the residents to receive unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were dated, labeled properly, and not expired in two of five medication carts. This failure had the potential to result in an altered effectiveness of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the manufacturer's guidelines, and policy and procedures for checking the sanitizing solution concentration. This failure could result in the potential to spread food-borne illness.