Health inspection·September 19, 2025

California Code of Regulations, Title 22, Division 5, Chapter 3, Section 72357. Pharmaceutical Service-Labeling and Storage Drugs. (i) Drugs shall be accessible only to personnel designated in writing by the licensee. (j) Storage of nonlegend drugs at the bedside shall meet the following conditions: (1) The manner of storage shall prevent access by other patients. Lockable drawers or cabinets need to be used unless alternate procedures, including storage on a patient’s person or in an unlocked drawer or cabinet are ineffective. California Code of Regulations, Title 22, Division 5, Chapter 3, Section 72523. Patient Care Policies and Procedures. (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (c) Each facility shall establish and implement policies and procedures, including but not limited to: (5) Pharmaceutical services policies and procedures. Code of Federal Regulations, Title 42, 483.25 (d) Accidents. The facility must ensure that- (d) (1) The resident environment remains as free of accident hazards as is possible. It was determined that the facility failed to ensure an environment free from accident hazards, when Patient 1 managed to gain access and ingest a packet of hydrocortisone (steroid ointment) without staff awareness. In addition, the incident on July 31, 2025, related to finding the hydrocortisone packet lodged in the patient’s throat was not thoroughly investigated by the facility. This failure resulted in the hydrocortisone packet getting lodged to the patient’s throat causing the patient to choke while eating, which could subsequently obstruct the patient’s airway leading to a loss of consciousness and death. Patient 1 was transferred to the general acute hospital (GACH), for evaluation and treatment. In addition, the facility failure to thoroughly investigate the incident placed the patient at risk of recurrence and further harm. On August 7, 2025, at 9:28 a.m., an observation was conducted with Patient 1. Patient 1 was observed sitting in a wheelchair in the dining room. Patient 1 was alert but not responding to interview questions. On August 7, 2025, Patient 1’s “Admission Record,” indicated the patient was admitted to the facility on August 27, 2013, with diagnoses which included right side hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of body), and dementia (memory loss). A review of Patient 1’s “Minimum Data Set (MDS - an assessment tool),” dated May 11, 2025, indicated the patient had a BIM (Brief Interview for Mental Status-an assessment tool to evaluate cognitive impairment) Score of 3 (meant severe cognitive impairment). The MDS data further indicated Patient 1 was non-ambulatory and needed substantial/maximal assistance on eating and oral hygiene. A review of Patient 1’s “…Change in Condition Evaluation…” dated July 31, 2025, at 10:18 a.m., indicated, “…Signs & (and) Symptoms Identified…other change in condition…unknown substance lodged in throat…Functional Status Evaluation…Swallowing Difficulty…Describe the swallowing difficulty…Associated with new onset or progressive choking, aspiration…” A review of Patient 1’s, “Progress Notes,” dated July 31, 2025, indicated the patient was transferred to the GACH by the paramedics (a person trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) on July 31, 2025, at 10:41 a.m.  A review of Patient 1’s GACH Emergency Room progress notes, dated July 31, 2025, indicated, “…Patient Visit Information…You were seen today for…H/O [history of] swallowed foreign body…FOREIGN BODY REMOVAL FROM BACK OF THROAT…WE REMOVED A HYDROCORTISONE PACKET FROM THE BACK OF PATIENT’S THROAT…Foreign Object in Throat, Removed…Objects that are swallowed can get stuck in the throat…A stuck object can cause coughing, choking, pain when swallowing, or trouble swallowing…The object has been removed. You are being sent home to recover...It may also hurt to swallow. This is because the throat tissues were irritated and injured. Symptoms should start to get better as the tissue heals...” A review of Patient 1’s GACH document titled, “…HPI [history of present illness]– General Illness,” dated July 31, 2025, at 11:22 a.m., indicated: - “…Chief Complaint Swallowed a foreign body, possibly a packet of sugar…The patient has some kind of foreign body located in the posterior pharynx [cavity behind nose and mouth] it is unclear what it is at this time. Because the patient’s dementia, he is unable to follow directions I am unable to remove it at this time without sedation [administer sedative drug to produce sleep or state of calm] …Procedural Sedation Note…Once the patient was adequately sedated, I was able to open the patient’s mouth and pulled out a small medication packet from the back of his throat. It was a packet of hydrocortisone…” A review of Patient 1’s “Progress Notes,” at the Skilled Nursing Facility (SNF), dated July 31, 2025, at 3:50 p.m., indicated the patient returned to the facility from the GACH. A review of Patient 1’s “Care Plan Report,” indicated, “…history of putting uneatable items in mouth and choking…episode 7/2/2023 [July 2, 2023] …episode 7/31/2025 [July 31, 2025]…Interventions...Frequent visual checks...Keep table free of clutter...” The care plan was initiated and created on August 7, 2025 (7 days after the choking incident). Upon review of Patient 1’s care plan, it was determined that there was no active care plan in place addressing the risk of aspiration or the patient’s history of placing non-edible items in his mouth prior to the incident on July 31, 2025. Furthermore, there was no documented evidence indicating that the facility had initiated or developed a care plan to address or prevent the recurrence of such an incident until August 7, 2025, which was seven days after the incident. A review of Patient 1’s “Order Summary Report,” at the SNF, for the month of August 2025, indicated that the patient did not have a current order for a hydrocortisone treatment. Further review of Patient 1’s record indicated no documented evidence regarding an investigation into the incident involving a foreign object (hydrocortisone packet) found in Patient 1’s mouth on July 31, 2025. On August 7, 2025, at 10:36 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated the following: - On July 31, 2025, he saw Patient 1 in bed at around 7 a.m., and he did not notice anything unusual; - While he (LVN 1) was passing medications on July 31, 2025, Certified Nursing Assistant (CNA) 1 alerted him that there was something lodged in patient’s (Patient 1) throat while she was trying to feed him; - He (LVN 1) could not tell what it was and tried to suction (a procedure of mechanically removing secretions, like mucus or other fluids, from a patient's airway) and get it out of the patient’s mouth; - He (LVN 1) called (name of an ambulance company) to send the patient out to the hospital. LVN 1 stated the hospital later informed the facility it was a hydrocortisone packet lodged in the patient’s throat; - The patient did not have a current order for hydrocortisone treatment; - The patient did not have a behavior of putting things into his mouth, prior to this incident (July 31, 2025, incident). The patient can grab things, but he was wheelchair bound (non-ambulatory) and bed bound (confined in bed due to disability making it difficult or impossible to move around or leave bed); - It was not acceptable that a hydrocortisone packet was found lodged in the patient’s throat. The hydrocortisone packet lodged in the patient’s throat could impact his breathing and could cause discomfort and placed the patient's life in danger. The incident could have been prevented by making sure the patient’s environment was clear of choking hazards; and -In addition, the patient should be closely monitored. On August 7, 2025, at 10:55 a.m., an interview was conducted with CNA 1, and she stated the following:   - She was the CNA assigned to render care to the patient (Patient 1) on July 31, 2025. The patient was a “feeder” (someone that requires assistance with being fed during meals);   - She (CNA 1) was assisting the patient to eat when she observed the patient “choking”. The patient was typically able to clear out his airway and cough; - She (CNA 1) informed LVN 1 of the patient's situation and the patient was transferred to the GACH; and   - The patient did not have a behavior of putting things in his mouth and it was not acceptable for the patient to have something lodged in his throat.   On August 8, 2025, at 1 p.m., a concurrent interview and record review was conducted with Treatment Nurse (TN) 1. TN 1 stated that she was the Licensed Nurses (LN) providing skin and wound treatment at the patient’s (Patient 1) station. TN 1 stated that the hydrocortisone medication was stored in a locked cart and at the central supply room, and there was no possibility a CNA or a patient would have access to the hydrocortisone packet.    On August 7, 2025, at 4:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the following:   - The patient had a change of condition on July 31, 2025, when the patient was “kind a choking”. There was something in the patient’s throat and staff thought it was a “piece of paper” and could not remove it;   - She was not aware it was a hydrocortisone packet lodged in the patient’s throat, and she thought it was a sugar packet;   - The patient was transferred to the GACH on the morning of July 31, 2025, and returned in the afternoon the same day;   - The patient had a history of grabbing and shoving inedible items in his mouth and the staff were not aware of this behavior. This behavior history was not relayed to the staff; - She did not investigate to determine the cause of the patient ingesting a hydrocortisone packet when it happened on July 31, 2025. The facility should have investigated the incident for the patient’s “sake and the sake of others.” The DON stated regardless of what it was, the facility should have figured out why the incident happened. The DON stated the consequence of not investigating the cause of the incident in a timely manner had the potential for a re-occurrence and may cause an “ill effect” on the patient (Patient 1). The DON stated she should have investigated the cause of the incident the next day (August 1, 2025); and   - There had been no changes in the patient’s care plan since the incident on July 31, 2025. There was no care plan addressing the incident of a hydrocortisone packet found lodged in the patient’s throat, on July 31, 2025. There should be a care plan to address the incident to prevent recurrence.   A review of the facility’s policy and procedure titled, “Accidents and Incidents – Investigating and Reporting,” dated July 2017, indicated, “…The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident…The nurse supervisor/charge nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident…Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities...” A review of the facility’s policy and procedure titled, “Medication Labeling and Storage,” revised February 2023, indicated, “…The facility stores all medications…in locked compartment…Only authorized personnel have access to keys…The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner…Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications…are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others…”   Based on interview and record review, it was determined that the facility failed to ensure an environment free from accident hazards, when Patient 1 managed to gain access and ingest a packet of hydrocortisone (steroid ointment) without staff awareness. In addition, the incident on July 31, 2025, related to finding the hydrocortisone packet lodged in the patient’s throat was not thoroughly investigated by the facility. This failure resulted in the hydrocortisone packet getting lodged to the patient’s throat causing the patient to choke while eating, which could subsequently obstruct the patient’s airway leading to a loss of consciousness and death. Patient 1 was transferred to the general acute hospital (GACH), for evaluation and treatment. In addition, the facility failure to thoroughly investigate the incident placed the patient at risk of recurrence and further harm. These violations, jointly, separately, or in any combination, presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.