Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0578
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to
participate in experimental research, and to formulate an advance directive.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, policy, and clinical record review, the facility failed to revise 1 of 1 sampled resident's (Resident
32) Physician Orders for Life Sustaining Treatment (POLST, a directive that specifies what services and
treatment an individual wishes in the event of an emergency or code blue such as resuscitation (CPR),
hospitalization, artificial hydration and tube feedings).
This had the potential for Resident 32 to receive end of life services and treatment that were against her
wishes and negatively impact her quality of life.
Findings:
A review of the facility's policy titled, Advance Health Care Directive (AHCD), dated [DATE], was reviewed.
The policy indicated, The IDT [Interdisciplinary Team, a team of health care professionals who work in a
coordinated fashion toward a common goal for the patient] is to review the resident's AHCD at the quarterly
care plan conference. If there is any change in the resident's status or desire, the physician is to be notified
to reassess the resident.
A review of Resident 32's admission Record showed that Resident 32 was admitted on [DATE] with
diagnoses that included, dementia, glaucoma (vision loss due to nerve damage from pressure in the eye),
high blood pressure, atrial fibrillation (an abnormal heart beat), weakness, and anxiety.
A record review of Resident 32's POLST, dated [DATE], which indicated, Do Not Attempt
Resuscitation/DNR and Defined trial period of artificial nutrition by tube.
A record review of a Physician's Order dated, [DATE], indicated that Resident 32 desired, DNR-COMFORT
CARE. NO ARTIFICIAL MEANS OF NUTRITION.
A record review of a Quarterly Interdisciplinary Care Conference, dated [DATE], held for Resident 32,
indicated that Advance Directives were reviewed with the resident and/or responsible party; and POLST
currently indicates: DNR-COMFORT CARE. NO ARTIFICIAL MEANS OF NUTRITION.
A record review of Physician's Orders, dated 6/2022, indicated that Resident 32 did not have the capacity to
make health care decisions.
During an interview on [DATE], at 8:50 am, the Social Services Director (SSD) confirmed that the POLST in
Resident 32's clinical record was incorrect and not consistent with the physician's order. The SSD
confirmed that during Resident 32's Care Conference meeting the IDT should have recognized
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 9
Event ID:
555625
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0578
that the POLST was incorrect and should have been changed and a new form filled out.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 2 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0604
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, clinical record and policy review, the facility failed to ensure that their restraint policy
was followed for 1 of 2 sampled residents (Resident 32), when a bed alarm and wheelchair alarm was
initiated for Resident 32 without informed consent (information given to the resident or responsible party
(RP) about the restraints and verification that they agreed to using them), a pre-restraint evaluation (a
determination that the restraint is necessary before initiating), a specific diagnosis (medical reason), or
reviewed by the Interdisciplinary Team (IDT, a team of health care professionals who work in a coordinated
fashion toward a common goal for the patient) within 72 hours after initiation.
Residents Affected - Few
This resulted in an unnecessary alarm restraint used on Resident 32, when there was no assessment or
consent for the restraint alarm.
Findings:
Facility policies were provided by the facility's corporate consultant. The facility's policy titled, Alarms dated
1/31/22, was reviewed and indicated, Alarms should initially be used for 72 hours to determine its
effectiveness in keeping the resident safe. The IDT should determine the effectiveness and decision to
continue or discontinue the intervention. Alarms that are to be used beyond the 72-hour assessment
period, require a Restraint Assessment to be completed. The resident or their representative are to consent
to the alarm use. A signed consent is to be filed in the resident's medical record.
The facility's policy titled, Physical Restraints dated 1/31/22, indicated, Alarms that prevent the resident the
freedom to move around, or cause fear in the resident who attempts to move independently, are considered
restraints. The facility's policy continued to indicate that a physician order must be obtained, and the order
was to specify the reason for the restraint manifested by a behavior and the medical symptoms being
treated by the restraint.
Resident 32's admission Record was reviewed and indicated that Resident 32 was admitted on [DATE] with
diagnoses that included, dementia, weakness, poor vision, hearing loss, and anxiety.
On 6/21/22 at 12:04 pm, Resident 32 was observed in her bed and a bed alarm was attached.
During an interview with Certified Nursing Assistant (CNA) E and concurrent observation of Resident 32 on
6/22/22 at 8:55 am, CNA E confirmed that Resident 32 had a bed and wheelchair alarm and stated, they
are to help prevent falls.
Resident 32's Physician's Orders, dated 6/2022, showed that on 6/1/22, an order was written for, Alarm:
Pad Alarm while in Bed and w/c [wheelchair]. Check placement and function of alarm [every shift] for
Patient Safety. The physician's order had not included the medical symptom or diagnosis that warranted the
alarm.
Resident 32's clinical record had not included a restraint assessment, IDT evaluation or re-evaluation,
within 72 hours of initiation, and there was no consent to use the alarms.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 3 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0604
Level of Harm - Minimal harm
or potential for actual harm
During an interview and concurrent clinical record review on 6/23/22 at 8:25 am, the Director of Nursing
confirmed that Resident 32's record had not contained a restraint assessment, IDT review, medical
diagnosis, or consent form.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 4 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
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 clinical record review, the facility failed to develop comprehensive care plans for 3 of 16
sampled residents. Two residents (Residents 32 and 213) were taking psychotherapeutic medications (a
medication that affects the mind, emotions and behavior) and 1 resident (Resident 313) was on hospice
care (supportive care to terminally ill residents that focuses on their comfort, quality of life, and being pain
free).
1. Resident 32 did not have a care plan developed for the use of Ativan (an anti-anxiety psychotherapeutic
medication that affects the mind, emotions and behavior).
2. Resident 213 did not have a care plan developed for the use of Seroquel (an antipsychotic
psychotherapeutic medication).
3. Resident 313 did not have a care plan developed for Hospice (care that focuses on the end of life wishes
of the terminally ill).
This had the potential for the staff not to implement interventions that were consistent with managing the
resident's behaviors, recognize the presence of adverse medication side effects, and implement end of life
choices.
Findings:
A review of the facility's policy titled, Care Plans dated 1/31/22, was conducted and indicated, The
resident's care plan is to be updated as changes occur including, but not limited to: Mood and behavior
changes; New and discontinued medications
A review of the facility's policy titled, Medications, Psychotherapeutic Drugs dated 1/31/22, was conducted
and indicated, The IDT[Interdisciplinary Team - a team of health care professionals who work in a
coordinated fashion toward a common goal for the patient] is to update the plan of care to address the
resident's behavioral symptoms, based on the assessment. And, The plan of care should demonstrate
interdisciplinary care planning directed toward resolution of the resident's problem.
1. Resident 32's admission record was reviewed showed that Resident 32 was admitted on [DATE] with
diagnoses that included, dementia and anxiety. Resident 32's Physician's Orders for 6/2022, showed that
Ativan 0.5 milligrams (mg) was ordered every 4 hours as needed for hitting, scratching and refusing care.
No care plan had been developed which identified these behavior problems or the risks and adverse side
effects associated with using Ativan.
During an interview and concurrent care plan review on 6/23/22 at 8:25 am, the Director of Nursing (DON)
confirmed that a care plan was not developed for Resident 32's use of Ativan.
2. An admission records face sheet was reviewed that indicated Resident 213 was admitted to the facility
on [DATE] with a heart rhythm abnormality, a fractured arm, and dementia.
A physician's order dated 4/19/22 for Resident 213 was reviewed for Seroquel 50 mg one tablet daily to
reduce paranoid behaviors.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 5 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
A review of Resident 213's care plans was conducted; no care plan addressing the use of, and potential
side effects of Seroquel was identified.
During a concurrent interview and record review was conducted on 6/23/22 5:10 pm, the DON confirmed
that there had been no care plan for Resident 213 for Seroquel use and confirmed that there should have
been a plan of care.
3. A review of Resident 313's medical records indicated he was readmitted to the facility on [DATE], with
diagnoses that included aspiration pneumonia (when food or liquid is breathed into the lungs), lung
disease, swallowing problems.
A review of Resident 313's physician order, dated 6/10/22, indicated Open to hospice, do not resuscitate,
comfort measures, and no artificial means of nutrition.
A review of Resident 313's care plans indicated that a care plan had not been revised since Resident 313
was readmitted to the facility and placed on hospice. Resident 313's most recent care plan was dated
4/26/22 and did not include hospice care interventions.
During a concurrent interview and record review on 6/23/22 at 10:20 am, Registered Nurse (RN C) stated
the facility's process was to revise and complete a comprehensive nursing assessment within 72 hours of a
resident's admission. RN C stated these timelines were very important so that staff were aware of what
care should be delivered to each resident. RN C confirmed a hospice care plan had not been developed for
Resident 313 since his re-admission and that his medical records did not include progress notes or alert
notes indicating Resident 313 was on hospice care. RN C stated this was a serious problem with the
communication process, especially since everybody is waiting on changes of care to be communicated.
During a telephone interview on 6/23/22 at 10:51 am, Hospice Nurse Manager (RNH) and Hospice
Outreach Coordinator confirmed their agency was providing hospice care to Resident 313. RNH reported
their agency developed Resident 313's agency hospice care plan on 6/14/2022 and faxed it to the facility
the same day.
During a concurrent interview and record review on 6/23/22 at 11:10 am, Registered Nurse (RN G)
confirmed that Resident 313 did not have a hospice care plan developed or implemented since his
re-admission on [DATE]. RN G confirmed that the hospice agency's care plan recommendations were
added to the facility's care plan so that staff were aware of Resident 313's hospice care updates.
During a concurrent interview and record review on 6/23/22 at 5:20 pm, Director of Nursing (DON) stated
the facility's process was to generate a resident's care plan within 72 hours of admission. The DON verified
that Resident 313's care plan was not developed until 6/23/22 and that there were no progress notes or
nursing notes indicating that Resident 313 was on hospice. DON stated that not creating a care plan placed
Resident 313 at risk for not receiving his desired hospice services.
A review of the facility's policy titled, Hospice and Comfort Care, revised 1/31/21, stated Implementing
Comfort Care The resident's plan of care is to be updated to reflect any changes in the care of the resident
The hospice agency providing the care and the facility is to collaborate on an updated and integrated plan
of care.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 6 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0756
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart,
following irregularity reporting guidelines in developed policies and procedures.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, clinical record, and policy review, the facility failed to ensure that the consultant pharmacist (CP)
A identified an irregularity in the Medication Regimen Review (MRR), for 1 of 1 sampled resident who was
taking Ativan (an anti-anxiety psychotherapeutic medication- medication that affects the mind, emotions
and behavior), and the facility had incorrectly monitored for the adverse side effects of an antidepressant
medication. (Resident 32)
This had the potential for unwanted adverse side effects to go unrecognized and impair the Resident 32's
quality of life.
Findings:
The facility's policy titled, Medications, Psychotherapeutic Drugs dated 1/31/22, was reviewed. The
Psychotherapeutic Reviews section directed, The consulting pharmacist is to review the psychotherapeutic
medications monthly and make recommendations as appropriate. The pharmacist is to advise physicians
regarding any recommendations regarding drug or dose adjustments.
A review of LexiComp, an online drug reference site for professionals, updated 6/20/22, was conducted and
indicated the adverse side effects of anti-anxiety medications included drowsiness, sedation, confusion,
and an increased risk for falls. These warnings were not included in the antidepressant side effects that the
facility had monitored.
Resident 32's admission Record was reviewed and indicated that Resident 32 was admitted on [DATE],
with diagnoses that included: dementia and anxiety.
Resident 32's Physician's Orders, dated 6/2022, showed that Ativan 0.5 milligrams was ordered every 4
hours as needed and included, Monitor Antidepressant side effects of Ativan.
Resident 32's electronic medication administration record (E-MAR), dated 6/2022, was reviewed and
indicated that side effect monitoring had been done for an antidepressant medication instead of an
anti-anxiety medication.
During an interview and concurrent MRR review on 6/23/22 at 8:25 am, the Director of Nursing (DON)
confirmed that there were no recommendation made on Resident 32's most recent MRR, dated 5/2022.
The DON confirmed that the adverse side effect monitor for an antidepressant for Resident 32 was
incorrect and stated, they should have been monitoring side effects for an anti-anxiety.
During an interview on 6/23/22 at 10:42 am, CP A confirmed that Resident 32 should have been monitored
for the adverse side effects of Ativan instead of those from an antidepressant and that was not identified on
the MRR.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 7 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to ensure that their medication error rate did not
exceed 5 percent or greater for two of seven sampled residents (Resident 51 and 15) when three
medication errors were observed within 32 opportunities when:
Residents Affected - Few
1. Resident 51 had two medications administered without following manufacturer's instructions.
2. Resident 15 was administered an inhaler without following manufacturer's instructions.
This failure resulted in the facility's medication error rate to be 9.38 percent and had the potential
medication to be ineffective for all residents.
Findings:
1. During a record review of a document titled admission Record indicated Resident 51, was admitted to
facility on 9/15/2021 for atrial fibrillation (A-fib an irregular heartbeat) and osteoarthritis (damage to joint
and bone).
A record review of the Resident 51's physicians orders dated 6/21/22, indicated, Allopurinol [treats arthritis]
100 milligrams (mgs), 1 tablet by mouth two times a day for osteoarthritis of the knee.
A record review of the Resident 51's physicians orders on 6/22/22 at 9:22 am, indicated Xarelto [prevents
blood clots for irregular heartbeat] 15 mg, give 1 tablet by mouth one time a day related to heart disease
and A-fib.
During an observation of medication administration on 6/22/22 at 8 am, Licensed Nurse (LN D)
administered Allopurinol and Xarelto to Resident 51 before the resident's breakfast tray had arrived.
Resident 51's bedside table had water only, no snacks. LN D did not offer any other food or water.
A record review of the manufacturer's instructions for Allopurinol indicated that the medication should be
administered after meals and with increased water.
During a review of Lexicomp (online medication resource), the manufacturer's directions for Xarelto stated,
Administer doses equal to or greater 15 mg with food This medication is in a class the Institute for Safe
Medication Practices (ISMP) includes among it's list of drug classes which have a heightened risk of
causing significant patient harm when used in error.
During an interview on 6/22/22 at 11 am, LN D stated, I did not know Allopurinol and Xarelto had to be
taken with food and confirmed that Resident 51's had not been delivered yet.
2. A review of Resident 15's admission Record indicated Resident 15, was admitted to the facility on [DATE]
for the diagnoses of dementia, diabetes, COPD (an incurable lung disease).
During a record review on 6/22/22 at 9:50 AM, titled Physician Orders indicated, Advair Diskus Aerosol
Powder Breath Activated 250-50 micrograms/dose (Fluticasone-Salmeterol), 1 puff inhale orally two times a
day for COPD.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 8 of 9
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
555625
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
California Park Post Acute
2850 Sierra Sunrise Terrace
Chico, CA 95928
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0759
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During a review of Lexicomp (an online medication reference) for Advair Diskus, the instructions indicated
Do not tilt disk. The instructions also stated that if the specific directions for administration were not
followed, it could cause ineffective use of the medication.
During a record review on 6/22/22 at 9:50 AM, titled Physician Orders indicated, Advair Diskus Aerosol
Powder Breath Activated 250-50 micrograms/dose (Fluticasone-Salmeterol), 1 puff inhale orally two times a
day for COPD.
During a review of the manufacturer's instructions for use of the Advair Diskus, indicated,
Step 2: Hold the Diskus in a level, flat position with the mouthpiece towards you Do not tilt the Diskus.
Step 3: Inhale your medication. Before you breathe in your dose from the Diskus, breathe out (exhale) as
long as you can Remove the Diskus from your mouth and hold your breath for about 10 seconds, or for as
long as comfortable for you.
Breathe out slowly as long as you can.
During an observation of medication pass on 6/22/22 at 8:52 AM, LN B administered Resident 15's Advair
Diskus inhaler. LN B held the inhaler incorrectly in an upward position instead of flat. LN B did not ask
Resident 15 to follow the proper oral inhalation procedure steps per written manufacturer's instructions; LN
B did not give verbal cues for teaching Resident 15 proper use of the inhaler for effective use.
During an interview on 6/22/22 at 10:40 am, LN B stated, I did not know I was holding the inhaler wrong
and I did not know that the resident needed to hold her medicine for 10 seconds.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555625
If continuation sheet
Page 9 of 9
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F578 - The right to request, refuse, and/or discontinue treatment, to participate in or
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
F604 - Respect and Dignity
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F756 - Drug Regimen Review
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
FAQ · About this visit
Common questions about this visit
What happened during the June 24, 2022 survey of CALIFORNIA PARK POST ACUTE?
This was a inspection survey of CALIFORNIA PARK POST ACUTE on June 24, 2022. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at CALIFORNIA PARK POST ACUTE on June 24, 2022?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate ..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.