Health inspection·June 14, 2024

F 0660 Plan the resident's discharge to meet the resident's goals and needs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure a safe discharge home for one resident (Resident 1) of three sampled residents when Resident 1 was discharged home without verified home health service arrangements. Residents Affected - Few This failure resulted in Resident 1 not receiving the necessary continuity of care for his wound. Findings: A review of Resident 1 ' s admission record indicated admission to the facility on 5/15/24 with diagnosis which included cellulitis (a deep infection of the skin caused by bacteria), disruption of external surgical wound (wound re-opening), and the necessity for change or removal of nonsurgical wound dressings. A review of Resident 1 ' s discharge plan documented by the Social Services Assistant (SSA) dated 6/5/24 at 12:21 p.m. indicated, Discharge Destination .Home alone .Will home Care be provided? .Yes .Estimated start date .6/11/24 .Home Care Services to be provided .PT- physical therapy .OT- occupational therapy .skilled nursing services . A review of a telephone order entered by the Social Service Director (SSD) dated 6/5/24 at 12:52 p.m. indicated, [Resident 1] to discharge home on 6/9/24 with home health RNx [nursing services for] medication/symptom management, PTx strengthening exercises/home safety, and OTx ADLs [activities of daily living such as toileting, eating, grooming, etc.] training and medication. Follow up with PCP [primary care physician] within 7-10 days of d/c [discharge]. Has wound vac to left groin s/p [status post] surgical debridement, to be changed every 72 hours. A review of Resident 1 ' s practitioner note written by the Nurse Practitioner dated 6/7/24 at 9:07 a.m. indicated, .[Resident 1] is to discharge home with home health .support .per SS [social service] [Resident 1] does have [PCP] and has a f/u [follow-up] appt [appointment] already set up .[Resident 1] has follow up appt with vascular surgeon .on 6/13/24. Hehas [sic] a f/u appt with his PCP on 6/17/24 .Examination .SKIN: left fem [femoral] site with wound vac [a machine which uses vacuum-assisted closure of wound to assist in wound healing] right fem site with moderate amt [amount] of slough .Home health nurse to evaluate within 1-2 days .Follow up with your Primary Care Provider in 5-7 days and your specialist as advised. A review of Resident 1 ' s Treatment Administration Record (TAR) dated June 2024 indicated, Change Wound Vac/Negative Pressure Wound Therapy; Negative Pressure 125 mmgHg [millimeters of mercury, a measurement of pressure] intermittent Cleanse with NS [normal saline, a solution used to clean wounds] or wound cleanser .Place black foam into wound. Apply skin prep to intact skin around the wound Page 1 of 3 555450 555450 06/14/2024 American River Center 3900 Garfield Avenue Carmichael, CA 95608

F 0660 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .Cover with occlusive dressing and secure tubing per manufacturer guide .every 72 hours for left groin s/p surgical debridement .Start Date 5/21/24 .D/C Date 6/9/24 . A review of Resident 1 ' s progress note dated 6/9/24 at 10 a.m. indicated, Wound Vac was beeping, re-enforced with extra dressing. Informed patient that he will be leaving with current wound vac and box placed by his bed would be the box he will be leaving with which was what the wound the [sic] vac came in. Wound Vac checked by this writer and RN [registered nurse]. A review of Resident 1 ' s progress note dated 6/9/24 at 4:43 p.m. indicated, resident DC home today, patient signed all paperwork, verbalized understanding of dc instructions . A review of all of Resident 1 ' s progress notes dated 6/5/24 to 6/9/24 showed no documented evidence social service or nursing staff called the home health agency to verify home health arrangements were set to be delivered within 72 hours of Resident 1 ' s discharge home. A review of Resident 1 ' s post discharge call back collection report dated 6/12/24 indicated, Home Health has not been in touch yet. [Resident 1] left several VM [voicemail messages] .educated pt [patient] that he should go to ER [emergency room] if worse or appt on 6/13 . A review of Resident 1 ' s social service note dated 6/12/24 at 1:35 p.mn. indicated, Called and talked .with [Home Health agency]. Said it was being processed. They were trying to find PCP. HH did reach out .and ask about PCP but gave the information that was not currant [sic]. SSA was able to give them PCP. They will call SS back with confirmation and schedule appt with [Resident 1]. In an interview on 6/14/24 at 3 p.m. with the Director of Nursing (DON), the DON stated, .wound vac dressing should be changed [every] 72 hours. In an interview on 6/14/24 at 3:40 p.m. with the Assistant DON (ADON), the ADON stated social services was expected to follow up with the home health agency to ensure services were scheduled to start prior to discharge. In an interview on 6/14/24 at 4 p.m., the ADON confirmed the home health agency did not render services to Resident 1 and acknowledged the discharge order for wound care was not carried out. In an interview on 6/15/24 at 9:14 a.m., with the Unit Manager (UM), the UM confirmed the expectation was for staff to coordinate with other departments to make sure Resident 1 had everything he needed prior to discharge, and everything should have been verified with the home health agency. The UM further stated it was very important to ensure the continuity of care for all residents ' health. In an interview on 6/15/24 at 11:49 a.m., the Administrator (ADM) stated she expected continuity of care for all residents upon discharge was ensured for the residents ' well-being. A review of an undated facility ' s policy and procedures titled Transfer or Discharge, Preparing a Resident for, indicated, A post-discharge plan .will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident ' s discharge or transfer from the facility . A review of an undated facility ' s policy and procedures titled Referrals, Social Services, indicated, Social services personnel shall coordinate most resident referrals with outside agencies 555450 Page 2 of 3 555450 06/14/2024 American River Center 3900 Garfield Avenue Carmichael, CA 95608

F 0660 Level of Harm - Minimal harm or potential for actual harm .Exceptions might include emergency or specialized services that are arranged directly by a physician or the nursing staff. Social services will collaborate with the nursing staff .to arrange for services that have been ordered by the physician. Residents Affected - Few 555450 Page 3 of 3