Health inspection·September 26, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan related to refusal of care, for one of two residents (Resident 1) who repeatedly refused to ingest the prescribed medications, reviewed for Quality of Care. The failure had the potential for medical complications and a decline in health status. Findings: Resident 1 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (a brain disorder), per the facility ' s admission Record. On 9/17/24, Resident 1 ' s clinical record was reviewed. According to the facility ' s census dated 9/17/24, , Resident 1 was no longer at the facility. The annual Minimum Data Set (MDS-a clinical assessment tool), dated 6/23/24, listed a cognitive score of 3, indicting cognition was severely impaired. According to the physician orders, dated 1/11/24, Sertraline (used for major depression) 25 milligrams (mg) Give one tablet by mouth one time a day for depression, Carvedilol (used to treat high blood pressure) 3.125 mg give one tablet by mouth two times a day for hypertension, Sacubitril-Valsartan (used to treat chronic heart failure) 24-26 mg, give one tablet by mouth two times a day for hypertension, Ranolazine ER (used to treat chronic chest pain) 500 mg, give one tablet by mouth two times a day. According to the physician orders, dated 3/12/24, Depakote Sprinkles (used to treat seizure disorder) 125 mg, give six tablets by mouth three times a day for seizures, Levetiracetam (used to treat seizures) 100 mg per milliliter (ml), give 12 ml by mouth two times a day for seizures, and Notify MD if blood sugar is less then 70 mg/deciliter (dl) and/or greater the 250 mg/dl. Check blood sugar two times a day for glucose (blood sugar level) monitoring. The Medication Administration Record (MAR) was reviewed from 8/1/24 through 8/15/24. The medication Sertraline for depression was refused and not administered for 4 out of 15 opportunities. The medication Carvedilol for high blood pressure was refused and not administered for 9 out of 30 Page 1 of 3 055064 055064 09/26/2024 Cottonwood Canyon Healthcare Center 1391 Madison Avenue El Cajon, CA 92021

F 0656 opportunities. There was no documented evidence the blood pressure had been checked. Level of Harm - Minimal harm or potential for actual harm The medication Sacubitril-Valsartan used for chronic heart failure was refused and not administered for 6 out of 30 opportunities. Residents Affected - Few The medication Ranolazine used for chronic chest pain was refused and not administered 9 out of 30 opportunities. The medication Depakote Sprinkles used for seizures was refused and not administered 13 out of 45 opportunities. The medication Levetiracetam used for seizures was refused and not administered 8 out of 30 opportunities. The blood sugar checks to monitor glucose levels was refused and not performed for 18 of 30 opportunities. There was no documented evidence a care plan had been developed for Resident 1 refusing medically necessary medications There was no documented evidence an interdisciplinary team (IDT) meeting had been conducted to address Resident 1 ' s repeated refusal of medications. According to the care plan, titled Seizure activity, dated 8/12/24, Resident 1 had a witnessed seizure on 8/12/24, which listed an intervention, Give patient seizure medication first and on time to avoid seizure activity. According to the care plan, titled Hypertension, undated, listed an intervention, Administer medication as ordered. According to facility ' s S-Bar Communication Form, developed on 8/14/24 at 7:50 A.M., Resident 1 had a blood pressure of 220/130. The Nurse Practitioner was notified and ordered Hydralazine (used to treat high blood pressure) 25 mg. The blood pressure was re-checked 30 minutes later and was 140/80. According to the facility ' s nurse ' s note, dated 8/15/24, at 3:30 P.M., Resident 1 was not responding to verbal or tactile stimuli. The nurse ' s note, dated 8/15/24 at 4 PM, indicated Resident 1 was, still unconscious and a family member requested Resident 1 go to the hospital for evaluation. There was no documented evidence Resident 1 ever returned to the facility after the hospital transfer on 8/15/24. An interview and record review was conducted with Licensed Nurse 2 (LN 2) on 9/17/24 at 12:45 P.M. LN 2 stated he was very familiar with Resident 1, who often refused to take his daily medication. LN 2 stated the physician, and nurse practitioner were aware of Resident 1 ' s the repeated medication refusals. LN 2 reviewed Resident 1 ' s August 2024 medication administration record and stated the Code #2, meant the medication was refused by the Resdietn. LN 2 stated, if he didn ' t want to take his medications that day, there was nothing anyone could do, to get him to take it. LN 2 stated he was sure there was a care plan for refusal of medication, because it happened so frequently. LN 2 reviewed Resident 1 ' s care plans and stated there was no care plan for refusal of taking medications and there should be one. LN 2 stated since Resident 1 was refusing important medications, it put him 055064 Page 2 of 3 055064 09/26/2024 Cottonwood Canyon Healthcare Center 1391 Madison Avenue El Cajon, CA 92021

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few more at risk for seizures and high blood pressure, which could lead to a worsening medical condition. LN 2 stated care plans were important to identify problems, so staff could have a consistently approach to resolving the issue. LN 2 stated care plans should be revised by the IDT, after they determined what was working or if a different approach was required. An interview was conducted with LN 3 on 9/17/24 at 1:06 P.M. LN 3 stated care plans identified potential problems and directed staff how to approach those problems, so desired goals could be reached. An interview was conducted with the Director of Nursing (DON) on 9/17/24 at 1:07 P.M. The DON stated Resident 1 should have had a care plan developed for his refusing medications. The DON stated since a care plan was not developed, staff were not able to consistently care for him with corrective approaches. Per the facility ' s policy, titled Care Plans, Comprehensive Person-Centered, dated March 2022, .3. The care plan intervention should be deprived from information .7. When possible, interventions should address the underlying source (s) of the problem . Per the facility ' s policy, titled Requesting, Refusing and/or Discontinuing Care and Treatment dated Feburary 2021, .5. If a resident/representative .refuses care or treatment, an appropriate member of the intersiciplinary team (IDT_ will meet with the resident/representative to: a. determine why .refusing .7. If the decision to refuse or discontinue treatment ressults in a significant change of condition, a reassessment will occur and appropriate changes with be made to the resident's care plan . 055064 Page 3 of 3