Health inspection·April 4, 2025

The following reflects the findings of the California Department of Public Health during the Re-Certification survey from 2/23/2025 to 3/3/2025: State Citation B was written Event ID: 1Q0G11 F757 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- §483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. The facility failed to ensure 13 out of 40 sampled residents (Residents 10, 19, 38, 39, 47, 53, 60, 67, 72, 93, 104, 111, and 121) were free from unnecessary medications when there was inadequate monitoring and systemic failure in the management of antihypertensive (medication to manage high blood pressure) and antiarrhythmic (medication to manage arrhythmia [abnormal or irregular heartbeats]) medications, and lack of monitoring for signs and symptoms related to the use of anticoagulants (medication to prevent blood clots). They are as follows: 1. During a medication pass observation, Licensed Vocational Nurse C (LVN C) failed to measure Resident 47's blood pressure (BP) before administering an antihypertensive medication, losartan 50 milligrams (mg, unit of measurement), to Resident 47. 2a. For Resident 104: - Nursing staff did not carry out the physician's order for daily BP monitoring. - He had a routine order for metoprolol (medication to lower BP and heart rate [HR]) with the direction to hold the medication if SBP less than (<)100 milliliters of mercury (mmHg, unit of measurement) and HR <60 beats per minute (bpm) order but the staff did not check the BP and HR daily before its administration. (Normal HR: 60 - 100 bpm) - He received daily amiodarone (a potent antiarrhythmic agent - medication to treat/prevent irregular or abnormal heart rhythms) without consistent and daily BP and HR monitoring, and without a comprehensive care plan. - He received four routine antihypertensive medications without daily BP monitoring: Metoprolol, Entresto (a combination medication for hypertension and heart failure [a condition when the heart cannot pump enough blood to meet the body's needs]), furosemide (a diuretic, or water pill, to remove excess salt and water, and thereby lowering BP), and spironolactone (a diuretic to manage hypertension). The nursing staff did not code the Medication Administration Record (MAR, official document where staff record medication administration and related monitoring) correctly to require the input of the required BP and HR before administration of these medications. The record review indicated there was a period where BP and HR were not checked for as long as 14 days, as follows: - Resident 104's BP was not checked for 14 days from 1/11/25 to 1/26/25; for 3 days from 1/26/25 to 1/30/25; for 7 days from 2/1/25 to 2/8/25; for 2 days from 2/9/25 to 2/12/25; for 5 days from 2/13/25 to 2/18/25; and for 6 days from 2/19/25 to 2/26/25. - Resident 104's HR measurement was not obtained for 14 days from 1/11/25 to 1/26/25; for 4 days from 1/26/25 to 1/30/25; for 11 days from 2/1/25 to 2/13/25, and for 8 days from 2/19/25 to 2/27/25. 2b. For six residents (Residents 10, 38, 54, 111, 121, and 287) receiving digoxin (an antiarrhythmic agent to treat heart failure and AF) - Resident 38 received digoxin 6 times when HR was outside of the prescribed parameter in January and February 2025 - Resident 111 had no HR obtained on 2/26/24, but digoxin was given - Resident 111 received digoxin daily since admission in June 2024 without monitoring for digoxin blood level (to monitor if the medication is within therapeutic range and to avoid toxicity) - Resident 10 had a physician's order to obtain digoxin level every 3 months since 4/1/24. There was no digoxin level done in July 2024, October 2024, and January 2025. - Six out of six residents did not have comprehensive care plan developed related to digoxin use (see F 656). 2c. The facility's consultant pharmacist (CP) failed to identify and report to the facility irregularities related to the above findings for above residents (Residents 10, 38, 54, 104, 111, 121, and 287) (See F 756) 2d. For eight residents (Residents 19, 38, 60, 67, 72, 93, 104, and 121) receiving amiodarone: - Eight out of eight residents had no documentation of BBW monitoring related to amiodarone - Eight out of eight residents had no documentation of BP and HR checks prior to administration of amiodarone until 2/28/2025 (day of survey); - Resident 72 received amiodarone on 2/28/2025 at 9:00 a.m. with BP of 95/87 when it was supposed to be held and the physician to be notified. - Seven out of eight residents did not have comprehensive care plan developed related to amiodarone use (see F 656). 2e. The competency checks for five licensed nurses (LNs) revealed one out of five LNs did not have nursing care competency and medication administration training (see F 726). The facility's noncompliance related to lack of monitoring of BP and HR prior to antihypertensive and antiarrhythmic medication administration and as ordered; hold parameters not being followed; lack of laboratory monitoring for digoxin level; lack of BBW monitoring for amiodarone; lack of hold parameters for these medications; inaccurate coding of the MAR; lack of comprehensive care planning; and lack of CP's recommendations or identification of irregularities related to these deficient practices had the potential for the residents to suffer adverse effects from severe hypotension or low BP (such as dizziness or lightheadedness, weakness, fatigue, confusion, blurred vision, nausea and vomiting) and worsening arrhythmias (such as chest pain, fainting, rapid or pounding heartbeats, sweating, collapse, and sudden cardiac arrest [heart stop beating suddenly]). Resident 104 had low BP readings on 1/7/25, 1/30/25, 2/1/25, 2/8/25, 2/13/25, and 2/19/25. Due to these systemic failures (as stated above) with the potential to affect all residents receiving antihypertensive and antiarrhythmic medications, the facility needed to take immediate action to correct the noncompliance. On 2/28/25 at 5:45 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator, the Director of Nursing (DON), and the Regional Director of Clinical Services (RDCS) related to lack of BP and HR monitoring prior to antihypertensive and antiarrhythmic medication administration and as ordered; lack of laboratory monitoring for digoxin; lack of BP, HR, and BBW monitoring for amiodarone; lack of hold parameters for these medications; lack of comprehensive care planning; and lack of CP's recommendations or identification of irregularities related to these medication use. On 3/3/25, at 1:48 p.m., the IJ was removed after the Administrator submitted an acceptable IJ Removal Plan ([IJRP], a plan with interventions to immediately correct the deficient practices, and after the survey team verified and confirmed the corrective actions while onsite. The acceptable IJRP included the following corrective actions: A. The facility identified residents whose BP and HR need to be monitored. All 59 residents with antihypertensive and antiarrhythmic medications have their updated orders for BP and/or HR check prior to administration, hold parameters, BBW monitoring, digoxin level (when applicable), and developed comprehensive care plan. B. The DON or RDCS in-serviced/trained 7 out of 8 clinical leadership members, and 34 out of 38 licensed nurses (LNs) on ensuring that residents with anti-hypertensive and antiarrhythmic medications have orders for BP and/or HR check prior to administration, hold parameters, BBW monitoring order, digoxin level (when applicable) is carried out, and care plan is developed for use of those medications. LNs who are on vacation or leave and any new registry licensed nurses will be provided in-service/competency training before they work on the floor. C. The CP was provided an in-service by his supervisor on reviewing and identifying medication irregularities during monthly medication regimen review on 3/1/2025. The CP performed an audit of all residents on anti-hypertensive and antiarrhythmic medications for any inconsistencies on BP and/or HR checks prior to medication administration and on applicable lab test recommendations for those medications. This audit was completed by 3/2/2025. D. The interdisciplinary team (IDT, team composed of members from different departments involved in a resident's care) will continue to conduct a daily review of new admissions orders and any new orders for anti-hypertensive and antiarrhythmic medications and verify that those required components are present and being followed. E. The clinical leadership team started with random observation of several LNs during medication pass on 3/1/2025 to ensure that BP and/or HR are checked prior to giving medication(s) and hold parameters are followed. F. The Medical Director (MedD) has been actively consulted and involved by the clinical leadership team on ensuring that all residents receiving medications have appropriate vital signs (measure of basic functions: body temperature, HR, respiratory rate, BP) monitoring and checks, have hold parameters, and applicable lab orders for use of medications. G. The Medical Records Director (MRD) or designee will continue to perform compliance audits to ensure that residents with anti-hypertensive and antiarrhythmic medications have orders for BP and/or HR check prior to administration, hold parameters, black box monitoring, digoxin level (when applicable), and care plan. H. Corrective Action Plan will be reviewed at QAPI [Quality Assessment and Performance Improvement] Committee Meeting for 6 months using pertinent compliance audit information and resolutions from March 2025 through the end of August 2025 or until the desired outcome of 100% compliance is achieved and sustained for at least six consecutive months. 3. Resident 47 received daily losartan with a hold parameter without the nursing staff monitoring the BP prior to its administration. 4. Resident 104 received amiodarone on 2/28/2025 at 9:00 a.m. with BP of 98/66 when it was supposed to be held and the physician to be notified, after the concerns had been raised with facility leadership staff. 5. Resident 39 received Xarelto (an anticoagulant to prevent blood clots) without evidence of staff monitoring for signs and symptoms related to its use. 6. For Resident 53, the nursing staff did not consistently monitor the signs and symptoms related to the use of Eliquis (an anticoagulant). The failures had the potential for residents to suffer adverse effects of the medications including undetected severe hypotension, worsening of arrythmias, and anticoagulant-related symptoms such as bleeding, bruising, discolored urine, black, tarry stools, lethargy, sudden changes in mental status or vital signs, shortness of breath, or nosebleeds, and untimely interventions for the residents. Findings: The BP is measured in millimeters of mercury (mmHg, unit of measurement) and in two numbers. The upper number is the systolic BP, or SBP, indicating the pressure in the arteries when the heart beats and pumps blood through the body; the lower number is the diastolic BP, or DBP, is the pressure in the arteries when the heart rests between beats. According to the American Heart Association, normal BP is less than 120/80 mmHg; and low BP is a reading lower than 90/60 mmHg (www.heart.org; accessed 3/6/25) 1. During a medication pass observation on 2/24/25 at 9:33 a.m., LVN C was observed preparing and administering 8 medications, including a tablet of losartan 50 mg, to Resident 47. During the concurrent interview and record review on 2/24/25 at 9:52 a.m., when asked about Resident 47's BP for the administration of losartan, LVN C stated a certified nursing assistant (CNA) had already taken it earlier that day. She reviewed Resident 47's BP in the clinical record which indicated the latest BP was obtained the day prior, on 2/23/25 at 16:08 (4:08 p.m.). LVN C stated she did not check the resident's BP earlier that morning. On 2/24/25 at 9:54 a.m., she was observed returning to Resident 47's bedside and obtained her BP. It was 156/70 mmHg. After returning to the medication cart, LVN C stated, "It was a mistake" and she should have checked the BP before giving the losartan. A review of Resident 47's clinical record indicated a physician's order, dated 5/21/24, for losartan 50 mg, give 1 tablet one time a day for hypertension "hold for systolic [BP] <110 [mmHg]." 2a. A review of Resident 104's admission record indicated he was admitted to the facility with diagnoses including pleural effusion (condition where excess fluid accumulates in the pleural space, the thin cavity between the lungs and the chest wall), heart failure, pulmonary edema (condition where excess fluid accumulates in the lungs, causing difficulty breathing), and unspecified peripheral vascular disease (slow and progressive circulation disorder caused by narrowing, blockage or spasms in a blood vessel). A review of the cardiologist's (physician specialized in heart medical conditions) After Visit Summary, dated 9/9/24, indicated the resident was assessed with "bruit" (abnormal sound in an artery caused by turbulent blood flow). A review of Resident 104's Minimum Data Set (MDS, a care area assessment and screening tool), dated 12/17/24, indicated he had a BIMS (Brief Interview for Mental Status, a test given by medical professionals that helps determine a patient's cognitive understanding, scored from 1 to 15) score of 11, which indicated his cognitive condition was moderately impaired. On 2/27/25, a review of Resident 104's physician's orders, and January and February 2025 Medication Administration Records (MARs), indicated the following orders and administration times: A. Four routine antihypertensive medications: - Valsartan (treat high blood pressure and heart failure) 40 mg 1 tablet twice daily for hypertension, dated 4/12/24. On 1/30/25, valsartan was discontinued and switched to Entresto (combination of valsartan and sacubitril, another antihypertensive medication) 24-26 mg twice daily. One 2/4/25, Entresto was reduced to one time a day for hypertension. Part of its order indicated to "Check BP" without specified frequency. Each of these medications was scheduled to be administered daily at 10 a.m. - Furosemide 20 mg, give 1.5 tablets (30 mg) one time a day for edema (swelling caused by a buildup of fluid in body tissues) and hypertension, dated 8/23/24. It was scheduled to be administered daily at 9 a.m. - Spironolactone 25 mg, give 1 tablet one time day for fluid retention, dated 12/26/24. It was scheduled to be administered daily at 9 a.m. - Metoprolol extended release (ER) 25 mg one time a day for hypertension, "hold for systolic BP < [less than] 100 [mmHg], [HR] <60 [bpm]," dated 4/12/24. It was scheduled to be administered daily at 10 a.m. (Normal HR is between 60 - 100 bpm). B. Amiodarone 200 mg, 1 tablet by mouth one time a day "for arrhythmia", dated 4/12/24. It was scheduled to be administered daily at 10 a.m. C. "Check BP Q [every] day one time a day 'call clinic if SBP is less than 100 [mmHg] consistently," dated 1/30/25. It was scheduled daily at 9 a.m. A review of the Package Insert (PI, document included in the package of a medication that provides information about that drug and its use) for amiodarone, revised 10/2018, indicated it an antiarrhythmic medication to treat ventricular arrhythmias (life-threatening heart rhythm disturbance where the ventricles [lower chambers of the heart] quiver instead of contracting normally) and atrial fibrillation (an