The Springs at Pacific Regent

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when:1. On the clean dish rack there was a cracked 7.5 quart plastic cambro container, two serving dishes that had food particles stuck on them and four wet mixing bowls stacked on a shelf.2. Refrigerated food items had a white, fuzzy substance growing on them and were stored alongside unspoiled food products. Two refrigerated peeled and cut cucumbers were wrapped in plastic and not labeled or dated.3. A large cambro container in the warming oven had a yellow, clear, liquid substance in it that was labeled as olives. Food particles and crumbs were in the drawers and on the shelves of the prep cart. A spatula was covered with a slimy, greasy coating. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the baseline care plan included person-centered care during mealtimes for one of fourteen residents (Resident 86) within 48 hours of the resident's admission. This failure to develop the baseline care plan within 48 hours of admission for mealtime assistance resulted in the resident calling to request mealtime set ups multiple times a day continuously since admission.

Inspectors wroteBased on interview and record review, the facility failed to provide proper pharmaceutical services when the Medication Administration Record (MAR) and Controlled Medication Count Sheet (CMCS) did not reconcile for two randomly selected residents (Resident 91 and 61). This failure had the potential to place Resident 91 and Resident 61 at risk for inaccurate pain medication administration and/or diversion (illegal distribution or abuse of prescription drugs) of controlled medications (medications that the use and possession of are controlled by the federal government).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices related to hand hygiene (washing hands with soap and water or using alcohol-based hand sanitizer) during wound care for one resident (Resident 51). As a result of this deficient practice, Resident 51 was at an increased risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to provide necessary care and services in accordance with professional standards of practice for one resident (1) reviewed for wound care and treatment. This deficient practice placed Resident 1 at risk for harm related to poor wound healing and infection.

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective infection control program when the facility did not: 1. Report coronavirus (COVID-19: A highly contagious respiratory disease caused by the SARS-CoV-2 virus) outbreaks to the local/state public health officials in a timely manner. 2. Review the facility infection control policies and procedures on an annual basis during a COVID-19 outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy for the location or season) at the facility. These failures had the potential to increase the risk of healthcare-associated infections for staff, residents, and visitors in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one medication (med) was administered per physician ' s order for one resident (2). Resident 2 ' s Insulin Lispro (med to control high blood sugar) was administered via injection, and not via insulin pump (medical device that supplies a continuous flow of insulin subcutaneously [beneath the skin]), as ordered. As a result, Resident 2 ' s blood sugar level dropped below a normal range. This failure had the potential to affect Resident 2 ' s health, comfort, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement person-centered care plans related to the monitoring and inspection of bed alarms (auditorial alarms that alerts caregivers when patients leave or attempt to leave their beds), for three of three residents (Resident 1, 2, and 3), reviewed for accidental falls. As a result, there was the potential for Resident 1, 2, and 3 ' s bed alarms to not be monitored for functionality and staff were unaware of the bed alarms were in use.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess post Fall Risk Evaluations to ensure a higher score was in place after an actual fall, in order to prevent future falls from occurring for one of three residents, (Resident 2) reviewed for Accidents related to falls. As a result, post Fall Risk Evaluation scores decreased after each fall, putting Resident 2 at risk for additional falls.

Inspectors wroteBased on record review the facility failed to ensure 2 of 13 sampled resident's (24 and 107) Physician Orders for Life Sustaining Treatment (POLST) document was acknowledged and signed by the resident's physician. As a result, the residents' end of life wishes may not have been followed.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 13 sampled residents (36) was properly assessed for a psychiatric diagnosis when he was prescribed, and administered antipsychotic and anti-seizure medications. As a result, Resident 36 received medications for a condition he did not have.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a care plan for 1 of 13 sampled residents (125). This failure had the potential risk of not providing appropriate and individualized care for Resident 125.

Inspectors wroteBased on interview and record review the facility failed to ensure the Medication Regime Review (MRR) identified 1 of 13 sampled residents (36) who was on multiple psychoactive medications without a psychiatric diagnosis. As a result, Resident 36 received inappropriate medications.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 13 sampled residents (53) had not been put on Trazodone for a non-FDA approved indication, which resulted in this medication becoming an unnecessary drug for Resident 53, as this medication had been prescribed without an adequate (FDA approved) indication. This deficient practice resulted in this resident receiving Trazodone for a clinical indication, which had not been FDA approved, which could have caused this resident harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medications were administered safely for 1 of 13 sampled residents (155). This failure had the potential to cause a medication error for Resident 155.

Inspectors wroteBased on observation and interview, the facility did not maintain the temperature range of a resident's room between 71° F and 81° F for 1 sampled resident (161). As a result, a resident was exposed to cold temperatures.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' reported concerns were acted upon promptly for three of the three consecutive resident council minutes reviewed. This failure had the potential for residents needs to not met, affecting their dignity and quality of life.

Inspectors wroteBased on interview and record review, the facility did not follow a physician's order on medication dosing for 1 sampled resident (163). As a result, Resident 163 exceeded the ordered maximum amount of acetaminophen (pain medication) per day.

Inspectors wroteBased on observation, interview, and record review, the facility failed to verify the accuracy of the meal trays prior to serving to the residents for one of four meal observations. This failure had the potential for residents to receive incorrect diet and food consistency.