Pacific Hills Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure to follow their policy and procedure (P&P) for pharmacy services overview for supply of prescribed medications (any substance used to diagnose, treat, relieve, or prevent diseases, and requires a written or verbal order from a licensed healthcare professional to be legally dispensed) were available to administer for one of two sampled resident (Resident 1). Above this failure had the potential to affect Resident 1's medical condition and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure to follow their policy and procedure (P&P) for hospice program (a specialized medical care and support for residents with a terminal illness who have an estimated life expectancy of six months or less) and nursing facility service agreement for one of three sampled resident (Resident 1) when: No documented evidence for coordinated plan of care between facility and hospice provider (a specialized healthcare organization that provides hospice care) for Resident 1. Above this failure had potentially affected person-centered plan of care (individual care, treatments, and goals to resident's cultural, personal values, and lifestyle), health, and psychosocial well-being for Resident 1.

Inspectors wroteBased on interview, and record review, the facility failed to ensure to schedule, conduct, and document interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals to their residents) care conference with resident/resident's representative (RP, an individual chosen by resident to act on behalf of resident for day today and healthcare decision making for resident) for four out of four sampled residents (Resident 1, 2, 3, and 4) when:There was no documentation for initial and quarterly IDT care conference for Resident 1;There was no documentation for initial IDT care conference for Resident 2; There was no documentation for quarterly IDT care conferences for Resident 3;There was no documentation for quarterly IDT care conferences for Resident 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety when:1. Staff incorrectly tested the Quaternary sanitizer solution; and,2. Staff performed incorrect thermometer calibration These failures had the potential to negatively impact the nutrition and health status of the facility's 95 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy and procedures (P&P) for advance directives (AD: a written instruction, such as a living will or durable power of attorney [a document that authorizes to act on behalf of resident] for healthcare when the individual is incapacitated) and physician orders for life-sustaining treatment (POLST: a document that specifies the medical treatments the resident wants to receive during serious illness) were followed for five of nine sample residents (Residents 1, 23, 123, 57, and 97) when there was lack of evidence advance directives were discussed and/or carried out with them. These failures could lead to the delivery of medical services against residents' goals and wishes.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications were stored and labeled appropriately when medications were found past their discard date in Station 3 and Station 4 medication carts. This failure resulted in expired medications being administered to the residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (IC: written permission before implementing a healthcare intervention) prior to administrating an increased dose of anti-psychotropic medication (medication capable of affecting the mind, emotions, and behavior) for one of three sampled residents (Resident 57). This failure resulted in the sampled resident receiving psychotropic medication without being informed about the risks and benefits of an increased dose.

Inspectors wroteBased on interview and record review, the facility failed to ensure Residents were free from unnecessary psychotropic medications (medications capable of affecting the minds, emotions, and behaviors) for one of three sampled residents (Resident 35) when there was no documented evidence of non-pharmacological (treatments and strategies that mange health conditions without using medications) approaches attempted before psychotropic medications (used to treat mental health condition) were administered for Resident 35. This failure had the potential for sampled resident 35 to receive unnecessary psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure to complete significant change in status assessment (SCSA: a comprehensive assessment after a major change in improvement or decline in resident's health condition using minimum data set tool [MDS: resident assessment tool]) within 14 days after discontinued hospice care (a specialized support system, focusing on resident's comfort, quality of life and dignity than cure for residents with serious illnesses with prognosis of six months or less) for one of three sample resident (Resident 57). This failure had the potential for putting into effect inappropriate plans of care for Resident 57.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop or implement comprehensive and person -centered care plans that included target symptoms, measurable objectives, and interventions for two of eight sampled residents (Resident 35 and 3) when:1. Intervention not followed for risk for fall care plan for Resident 35; and,2. No care plan developed related to use of medication quetiapine (anti-psychotropic medication, used to treat mental health conditions with behavior concerns) for Resident 3. These failures had the potential to result in not meeting sampled residents' needs and plan of care.

Inspectors wroteBased on interview and record review, the facility failed to update and revise comprehensive and individualized care plans for hospice care (a specialized support system, focusing on resident's comfort, quality of life and dignity than cure for residents with serious illnesses with prognosis of six months) after hospice care services was discontinued for one of three sample resident (Resident 57). This failure in care planning had the potential for not meeting Resident 57's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received the necessary care and services for two of four residents (87 and 132) when:1. Resident 87's oxygen tubing was not changed weekly as ordered by the physician; and,2. Licensed vocational nurse C (LVN C) and licensed vocational nurse D (LVN D) did not know Resident 132 had a pacemaker (a small, battery-operated electronic device implanted in the body to regulate heartbeats), and Resident 132's pacemaker information was not in his medical records. These failures had the potential for adverse effects on the patients' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to identify fall risk to prevent falls for one of five residents (87) when Resident 87's fall risk was not assessed after he fell. This failure had the potential for Resident 87's fall risk score and interventions to be inaccurate.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 12% when 3 medication errors occurred out of 25 opportunities during medication administrations for two out of 10 residents (27 and 72). This failure resulted in medications to not be given in accordance with the prescriber's orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to accommodate food preferences for one of 4 sample resident (Resident 85). This failure had the potential for decreased meal intake, thus negatively affecting the health and well-being for the sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared palatable (quality of taste) for one of eight sample resident (Resident 97) when food was overcooked and lacked flavor. This failure had the potential to affect meal intake and the nutritional value of the food served to Resident 97.

Inspectors wroteBased on interview and record review, the facility failed to ensure communication with the hospice facility for one of seven residents (Resident 7) who were admitted to hospice, when a plan of care from hospice was not located. This failure had the potential to negatively affect the proper care and coordination of care of residents admitted to Hospice.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to implement infection control practices when:1. Certified nursing assistant I (CNA I) did not remove gloves before walking out of Resident 45's room;2. Registered nurse G (RN G) picked up the water pitcher on her medication cart with her contaminated gloved hand;3. Licensed vocational nurse H (LVN H) did not cleanse her hands and change gloves before administering eye drop to Resident 93; and,4. LVN H administered oral medications to Resident 76 with a contaminated spoon. These failures had the potential to spread infection in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive, resident-centered care plan for one out of three residents investigated, (Resident 1), when Resident 1 did not have a care plan for his broken tooth. This failure had the potential to result in the resident, not receiving the proper intervention and monitoring necessary to maintain his highest level of well-being.

Inspectors wroteBased on interview and record review the facility failed to have a procedure in place to ensure a resident who displays, or who has a mental disorder, receives appropriate treatment and services to correct the assessed problem for one of two sampled residents (Resident 1). The facility did not implement the psychiatry recommendations timely for Resident 1 after their assessment and psych evaluation was completed due to the facility not having a procedure to follow up with the recommendations from outside referrals. This failure resulted in a delay of starting Resident 1's new treatment plan by three weeks. This failure had the potential to negatively affect Resident 1's behavior and the safety of other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to report the results of its abuse investigations to the State Agency (California Department of Public Health-CDPH) within five working of the incident for two of three sampled Residents (Resident 1 and Resident 2). When: 1. The facility failed to report the results of the investigation of Resident 1's verbal abuse allegation to CDPH within five working days of the alleged incident. 2. The facility failed to report the results of the investigation of Resident 2's psychological abuse allegation to CDPH within five working days of the alleged incident. These failures resulted in CDPH being unaware of the outcome of Resident 1's verbal abuse allegation investigation and Resident 2's psychological abuse allegation investigation. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Alleged or Suspected Abuse and Crime Reporting for two of three sampled residents (Resident 1 and Resident 2) when: The facility failed to provide thorough summary of findings including information obtained in interviews for abuse investigations for Resident 1 and Resident 2, to the State Agency (CDPH-California Department of Public Health) upon request. This deficient practice resulted in CDPH being unaware if the abuse allegations by Resident 1 and Resident 2 were investigated thoroughly.

Inspectors wroteBased on interview, record 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 a Minimum Data Set (MDS) assessment for 1 (Resident #13) of 3 residents reviewed for MDS discrepancies accurately reflected the resident was receiving an antiplatelet medication, instead of indicating the resident received an anticoagulant medication.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of three residents (Resident 1) received the necessary care and services when: 1a. The interdisciplinary team (IDT - a group of health care professionals from diverse fields who work toward a common goal for residents) did not develop a change in condition plan of care (POC) for Resident 1; 1b. There was no close monitoring of Resident 1 for signs and symptoms of hypoglycemia (low blood sugar level) and no documentation of hypoglycemia protocol in Resident 1's clinical record; and 1c. Licensed nurses did not follow Resident 1's physician order for post operative (post-op, aftercare assessment and treatment after a surgery) follow-up with the surgeon. These failures had the potential to affect resident's care, health, and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to assess, notify to physician and Resident's responsible party (RP: person act on behalf of resident), and document pressure injury (injury to skin and underlying tissue resulting from prolonged pressure on the skin) on bilateral (both) buttocks for one of two sampled resident (Resident 1). This failure had the potential for delayed wound healing, adverse effects on the health and wellbeing of Resident 1.

Inspectors wroteBased on interview and record review the facility failed to provide needed care or services based on professional standards of practice to one of three sampled residents (Resident 1) when: 1. Resident 1 did not receive a Magnetic Resonance Imaging (MRI-scanner that uses magnetic and radio waves to generate images of the organs in the body) and physician was not notified regarding refusal of Resident 1; and 2. There was no documented evidence the physician was notified regarding the refusal of the MRI for Resident 1. These failures had the potential to negatively affect Residents 1 ' s health, due to the potential of an undiagnosed injury.

Inspectors wroteBased on interview and record review, the facility failed to make notification of resident's change in condition for one of three sampled residents (Resident 1) when: 1. There was no documented evidence the nurses were notified by physical therapist (PT) and occupational therapist of Resident 1's sudden unsteadiness and impairment in balance; and 2. There was no evidence licensed nurses notified the physician and Resident 1's responsible party regarding the high blood pressure (BP, the pressure of blood pushing against the wall of your arteries) readings. These failures had the potential to negatively affect the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accident-free environment for 10 of 18 residents reviewed for fall, when: 1. Resident 10 had no fall risk assessment and neuro-checks (evaluation of person's nervous system) completed after she fell on floor on 1/10/21 and 2/07/21 while she was turning on her bed. Also, staff did not develop a new fall prevention intervention to prevent fall recurrence. Resident 10 complained of headache, neck and back pain and was transferred to the hospital for evaluation. 2. For Resident 19, the facility did not complete neurochecks and fall risk assessments after each fall episodes. Also, Resident 19's fall care plan did not develop new interventions to prevent fall recurrence. Resident 19 fell on the floor from the wheelchair in her room on 5/6/21 while attempting to use the restroom. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure three of 18 sampled residents (Residents 40, 43, and 78) who required dialysis, received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and intake and output (I & O) monitoring, and coordination with dialysis centers done. These failures could increase the risk for complications, and potential miscommunication between the facility and dialysis center.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate accountability and effective storage of controlled medications (those with high potential for abuse or addiction) when: 1. Discontinued controlled medications for 11 discharged residents were not removed timely from one of two medication carts (Med Cart #1) to prevent medication errors and potential for loss and misuse; and 2. Random controlled medication use audit for four out of four residents (Residents 10, 25, 67, and 291) did not reconcile. The medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) to indicate they were given to the residents. The failure had the potential for misuse or diversion of controlled medications.

Inspectors wroteBased on interview and record review, the facility's consultant pharmacist (CP) failed to identify and make recommendations to the facility regarding irregularities related to the residents' drug regimen for four of 18 sampled residents (Residents 17, 73, 22 and 82). These failures resulted in inadequately monitored medications, which could lead to unsafe and ineffective medications for residents, and unnecessary medications for the residents, which had the potential to place them at risk for harm or adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 5 of 18 sampled residents (Residents 7, 17, 22, 73 and 82) were free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behaviors) when: 1. Resident 7 received a high dose Seroquel (an antipsychotic medication) for physical aggression without evidence of physical aggression; without adequate indication for use; without a gradual dose reduction (GDR, tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose); and the staff failed to report to the physician the resident had been oversleeping (possible side effect of her medications) during the day; 2. Resident 22 was on mirtazapine (an antidepressant medication) for poor appetite without evidence of poor meal intake for the past three months; [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 15.63% when five medication errors occurred out of 32 opportunities during medication administration for three out of six residents (Residents 40, 54, and 65). The deficient practice resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications, which may result in residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Many opened multi-dose eye medications, inhalers, and insulin (medication to lower blood sugar level) vials were dated with an open and discard date, to make sure they were not used beyond the discard date; 2. Many expired medications were not available for resident use; and, 3. Disposed medications and sharp medical instruments/devices were not accessible to unauthorized persons such as staff, residents, visitors, or anyone passing by the storage area. The deficient practices had the potential for unsafe and ineffective use of medications being used past the expiration date, and risk for lost/stolen, misuse, or abuse of disposed medications and devices.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain standards of food service safety when: 1. One of four dietary staff were working in the kitchen with unrestrained hair and, 2. One of two ice machines had a drain pipe outlet located at approximately the sa.m.e height as the top rim of the floor sink into which the pipe drained. When staff prepare food with unrestrained hair, a potential exists for residents' food to become conta.m.inated with fallen, unrestrained hair. An ice machine drain pipe outlet located too close in proximity to a floor sink has the potential to become contaminated with sewage, if the floor sink were to flood with sewage from a clog or backflow in the sewage system. 1. During an observation with the dietary manager (DM) on 07/06/21 at 8:40 a.m., Dietary Aide A (DA A) was in the kitchen food preparation area with unrestrained hair. [...]

Inspectors wrote1. During an observation on 7/6/2021 at 1:44 p.m., Resident 289 had an oxygen concentrator (machine used to deliver oxygen to the resident) in his room. The nasal cannula (tubing attached to the oxygen concentrator) was not labeled with a date. During an observation and concurrent interview with Resident 289 on 7/6/2021 at 3:41 p.m., the nasal cannula was still not labeled with a date. Resident 289 stated the last time he used his oxygen was earlier that day. During an observation and concurrent interview with registered nurse E (RN E) on 7/8/2021 at 8:26 a.m., Resident 289 was lying in bed receiving oxygen by way of nasal cannula. The nasal cannula was still not labeled with a date. RN E confirmed this observation. During an interview with RN E on 7/8/2021 at 8:33 a.m., she confirmed that Resident 289's nasal cannula should have been labeled with a date. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat one of 18 residents (Resident 21) with respect and dignity when staff did not ask permission from the resident before performing any procedure. This failure had the potential to cause emotional distress to Resident 21.

Inspectors wroteBased on interview and record review, the facility administered a psychotropic medication (drug that affects brain activities associated with mental processes and behavior) to one of 18 sampled residents (Resident 73) without informed consent from the resident. This failure had the potential to compromise the resident's right to be informed of, and participate in, his treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respond to residents' call lights in a timely manner for two of five sampled residents (Residents 32 and 38), when: 1. Resident 32's call light was not placed within reach, and 2. Resident 38 waited 15 minutes for help to get up in the wheelchair. This failure resulted in the delayed response to residents' needs and could potentially cause resident emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for three of 18 sampled residents (Residents 82, 84 and 83). Failure to accurately assess had the potential to result in unmet care needs for the residents.

Inspectors wroteBased on interview and record review the facility failed to complete the pre-admission screening and resident review (PASARR) for one of 18 sampled residents (Resident 343).

Inspectors wrote2. Review of Resident 72's facesheet included diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, fear, or anxiety strong enough to interfere with daily activities), adjustment disorder with depressed mood, major depressive disorder (a mental health disorder characterized by persistent loss of interest in activities causing significant impairment in daily life), psychotic disorder with delusions (a severe mental illness in which a person cannot tell what is real and what is imagined). During a record review and concurrent interview on 7/8/21 at 9:23 a.m., minimum data set nurse D (MDSN D) reviewed Resident 72's PASARR completed on 2/25/21 that indicated Section V (Mental Illness) item 27 with missing response, and item 29 with incorrect response. MDSN D stated if these two items were correctly coded it would require Level II PASARR evaluation. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a resident centered care plan for monitoring of a resident's surgical incision (also known as surgical wound, a cut through the skin made during surgery) and urostomy (surgical procedure that creates an opening in the belly to which urine passes), use of antibiotic (medication to treat infection) for one of 18 sampled residents (Resident 343). A baseline care plan is needed to provide effective and person-centered care of the resident that meet professional standards of quality care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services for gastrostomy tube (GT, a tube surgically placed into the stomach used for feeding and medication administration) for two of 18 sampled residents (Residents 337 and 83), when: 1. For Resident 337, the head of the bed was in an almost flat position, the disconnected GT tubing was not capped, the GT site dressing, asepto syringe used to flush the GT before and after medication administration, and GT administration tubing were not dated. 2. For Resident 83, staff did not label and date the GT formula bag and administration tubing. These failures posed the risk for complications related to the GT.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the peripherally inserted central catheter (PICC, a thin flexible tube inserted into a vein in the upper arm and guided into a large vein above the right side of the heart to obtain intravenous access for medication administration) line care for one of two residents (Resident 343) were done per professional standards of practice when: 1. Registered nurses (RNs) did not follow the physician's orders of PICC line dressing changes, measure and document external catheter length and arm circumference on admission. 2. Registered nurse did not follow the correct procedure of PICC line dressing change and measurement of upper arm circumference during dressing change observation. 3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate pain management for one of 18 residents (Resident 337) when prior care coordination between Rehab staff and nursing was not done to make certain the need to premedicate the resident before rehabilitation treatment (assessment, evaluation and treatment) was initiated. This failure had contributed to Resident 337's pain and discomfort.

Inspectors wrote2. Review of Resident 22's physician orders dated 3/23/21 included Basaglar KwikPen solution, Pen Injector 100 units/ml. (milliliter, unit of measurement), (Insulin Glargine) 10 units subcutaneously (under the skin) one time a day for DM 2 (diabetis mellitus type 2- insulin dependent diabetis). During an interview and concurrent record review on 7/12/21 at 10:02 a.m., the minimum data set nurse D (MDSN D) reviewed Resident 22's clinical record and did not find a care plan developed regarding resident's risk for hypo/hyperglycemia related to insulin use. The MDSN D stated base line care plan was important especially for residents with DM and she would develop one. Based on interview and record review, the facility failed to ensure two of 18 sampled residents (Resident 22 and Resident 43) were free from unnecessary medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 40) was free of a significant medication error when he received Humulin Regular (R) (short-acting insulin, medication to lower blood sugar level) nine (9) dosages past the discard (expiration) date. This deficient practice had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the resident.