The Californian

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for the use of the anticoagulant medication Apixaban (a medication that helps prevent blood clots) for one of two sampled residents (Resident 39). This failure could result in medication related adverse events and poor management of anticoagulation therapy for Resident 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were followed for two of two unsampled residents (Residents 29 and 14) when: 1. Resident 29's apical pulse (AP - heartbeat that is felt or heard at the apex [top] of the heart, located on the left side of the chest) rate was not checked, as ordered, prior to receiving a blood pressure medication. 2. Resident 14's medical record had no documented intervention, as ordered, during two episodes when the resident had alarmingly low blood sugar readings. These failures had the potential to result in Resident 29 and 14 not receiving the appropriate care and services which can affect their health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen tubing for one of two sampled residents (Resident 98) was labeled and dated. This failure had the potential to result in cross-contamination (the transfer of harmful bacteria) for residents in an already compromised condition.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure kitchen and food storage sanitation was maintained when: 1. Kitchen staff personal belongings (i.e., jacket and purse) were found inside the dry food storage room. 2. The low-temperature dish machine was operating without proper chemical sanitation. These failures increased the risk of food-borne illnesses to its vulnerable residents as a result of potential food contamination and improperly sanitized dishware.

Inspectors wroteBased on record review and interview, the facility failed to ensure the completed MDS (Minimum Data Set - a federally mandated health status screening and assessment tool used for all residents of long-term care health facilities) discharge assessments for two of two sampled residents (Residents 11 and 33) were submitted in a timely manner. This failure had the potential to result in resident data inaccuracies which could affect the facility's improvement efforts to provide high quality care to its residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Develop a person-centered interdisciplinary team nutrition care plan (IDTNCP - detailed plans of care created by representatives from several medical disciplines or specialties) for one of 16 sampled residents (Resident 37) to include the resident's goals and desired outcomes. In addition, the IDTNCP lacked clear and specific measurable objectives and physician input, related to a planned weight gain for Resident 37. This failure resulted in unclear measurable weight gain goal and impedes the IDT from effectively monitoring, evaluating and revising the care plan, as appropriate, to ensure care needs would not go unrecognized and unmet. 2. Develop a care plan for one of 16 sampled residents (Resident 35) receiving blood thinners. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain and provide a prescribed, routine antihypertensive medication (a medication used to lower blood pressure) ordered for one of three sampled residents (Resident 40). This failure had the potential to result in uncontrolled blood pressure levels and subsequent complications for Resident 40.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's Consultant Pharmacist (CP) identified and reported irregularities during the medication regimen review (MRR) when nonpharmacological interventions (NPI) were not implemented for the behaviors exhibited for depression and psychosis for one of 16 sampled residents (Resident 34) This failure had the potential to result in Resident 34 receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure its medication error rate during medication pass observation was less than five percent (5%). The facility had a cumulative medication error rate of 10.34% when three errors out of 29 opportunities for errors were observed between two licensed nurses (LN 2 and LN 4) who administered medication to two sampled residents (Residents 25 & 40) and one unsampled resident (Resident 547). The observed medication administration errors were: 1. LN 4 administered one capsule of Urox (a medication that supports bladder control) by mouth to Resident 25 instead of the prescribed order of two capsules. 2. LN 2 failed to administer the full dose of Clearlax (a laxative to treat occasional constipation) mixed in apple juice to Resident 547 when half of the mixture was thrown away. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications and medical supplies were discarded and not readily available for staff use. This failure had the potential to result in unsafe medication administration or ineffective therapy provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food handling when puree chicken, a TCS food (Time-Temperature Control for Safety - food that requires time-temperature control to prevent the growth of bacteria), was not accurately cooled down. As a result, the residents who were scheduled to be served the planned alternate entrée of puree chicken, in lieu of the main entrée of puree fish, were placed at an increased risk for developing a foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure documentation of non-pharmacological interventions (NPI - any intervention intended to improve the health or the well-being of individuals that do not involve the use of drugs or medicine) for the use of psychotropic medications (medications used for mood and behavior modification) in one of three sampled residents (Resident 34) was in place. Resident 34 was placed on Prozac (medication to treat depression) and Seroquel (medication to regulate mood, behaviors and thoughts) with no documented NPIs. This failure had the potential to result in incomplete data used as basis for possible continued or discontinued use of psychotropic medication usage on Resident 34 and other residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 45) was not prescribed a PRN (as needed) psychotropic medication (drugs used to treat mental illness) past 14 days, without a rationale for continuation for its use. This failure placed Resident 45 at risk for receiving an unnecessary psychotropic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals (medications made from living cells) were labeled correctly when two bottles of Vitamin C supplements had torn off expiration dates and three bottles of Glucerna Shakes (protein supplement) were expired. This failure had the potential to expose residents to expired medications with questionable effectiveness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment (POLST-a care directive during life threatening situations) and/or the resident's electronic medical record (EMR) orders were reflected of the residents' or responsible parties (RP) wishes for two of 16 sampled residents (Resident 26 and Resident 37) when: 1. Resident 26's POLST did not match the EMR medical doctor (MD) order. 2. Resident 37's POLST was not signed by the appointed RP/health care decision-maker. These failures had the potential to cause a delay or violate resident's rights, as to wishes on administering life-sustaining treatments during an emergency.