Health inspection·October 11, 2024

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 1 ' s right to be fully informed of her discharge and the possibility for appeal was protected, when Resident 1, who was deemed unable to make health care decisions, signed the notice for her discharge on [DATE] and was discharged on 7/15/24. Resident 1 ' s responsible party (RP) was not provided notice of the discharge appeal process. This failure resulted in Resident 1 ' s responsible party being uninformed of the right to appeal the discharge decision, with the potential that Resident 1 would not receive additional services needed if an appeal was sought and upheld. Findings: A review of Resident 1 ' s Resident Face Sheet, indicated she was readmitted to the facility in the summer of 2024 with diagnoses which included unspecified dementia (a progressive state of decline in mental abilities), severe. A review of Resident 1 ' s CALIFORNIA ADVANCE HEALTH CARE DIRECTIVE, dated 11/6/2023, indicated, DESIGNATION OF AGENT. I hereby designate my husband, [name], as my agent to make health care decisions for me .if my agent is not available to make a health care decision for me, I designate my daughter and my son. WHEN AGENTS AUTHORITY BECOMES EFFECTIVE. My agents authority becomes effective when my primary physician determines that I am unable to make my own health care decisions. A review of Resident 1 ' s physician order, dated 7/8/24, indicated, Resident is not capable of making his/her own health care decisions. A review of Resident 1 ' s NOTICE OF PROPOSED TRANSFER/DISCHARGE, dated 7/11/24, indicated Resident 1 ' s signature with the handwritten date next to her name as 7-11-202424. A review of Resident 1 ' s Notice of Medicare Non -Coverage (NOMNC, document that informs beneficiaries when their covered services are ending and of their right to appeal the decision), dated 7/11/24, indicated Resident 1 ' s signature with the handwritten date next to her name as 9-2-22-24-20024. 7-11-11. 7/11/24. A review of Resident 1 ' s clinical record, RESIDENT PROGRESS NOTES, dated 7/11/24, at 3:53 PM, indicated, CASE MANAGEMENT. Met with resident to discuss discharge planning. Informed resident that she has last cover date under [insurance provider] of 7-14-24. Resident signed NOMNC with last cover date of 7-14-24 and signed the Proposed Notice of Transfer of 7-15-24. Page 1 of 5 555713 555713 10/11/2024 Meadowood A Health and Rehabilitation Center 3110 Wagner Heights Road Stockton, CA 95209

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A review of Resident 1 ' s clinical record, RESIDENT PROGRESS NOTES, dated 7/11/24, at 4:02 PM, indicated, Daughter called back updated her regarding LCD [last covered day] 7/14/24, dc [discharge] 7/15/24. The documentation did not indicate information was provided of the right to appeal the discharge decision. During an interview on 10/11/24, at 3:03 PM, the Case Manager (CM) stated the NOMNC was provided to residents and their responsible parties three days before discharge to provide an opportunity to appeal. The CM stated she usually reviewed the physician orders prior to having the documents signed to determine if the resident had decision making capacity. The CM stated she did not check Resident 1 ' s orders for decision making capacity prior to having her sign the transfer paperwork because Resident 1 was alert. The CM further stated she should have verified Resident 1 ' s capacity before she had her sign the documents. A review of a facility policy titled Notice of Proposed Transfer/Discharge,revised 1/20/18, indicated, Our community shall provide a resident and/or the resident ' s representative written notice of an impending transfer or discharge. The resident and/or representative will be provided with the following information. A statement of the resident ' s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests, and information on how to obtain an appeal form, assistance in completing the form and submitting the appeal form, submitting the appeal hearing request. 555713 Page 2 of 5 555713 10/11/2024 Meadowood A Health and Rehabilitation Center 3110 Wagner Heights Road Stockton, CA 95209

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain the necessary medications for one of three sampled residents (Resident 1) when Resident 1 ' s Intravenous (IV, in the vein) antibiotic (medication to treat infections) and a pain-relieving medication for migraine headache were not available for use. These failures had the potential to cause prolonged illness for Resident 1 as well as unrelieved pain. Findings: a. A review of Resident 1 ' s SNF [Skilled Nursing Facility] admission HISTORY AND PHYSICAL, indicated she was admitted to the facility on [DATE], at 5:30 PM, with diagnoses which included bronchiectasis (condition in which the airways become damaged, making it hard to clear mucous) with pseudomonas/klebsiella (a group of germs that can cause severe infections and are only treated by certain antibiotics) and migraine (a headache that can cause moderate to severe throbbing pain and pulsating sensation). A review of Resident 1 ' s SNF Summary for Placement, printed 5/26/24, at 2PM, indicated, Medications Cefiderocol [antibiotic for difficult to treat infections] give intravenously every 8 hours for 5 days. A review of Resident 1 ' s Medication Administration Record (MAR) for May 2024, indicated, Fetroja [cefiderocol] every 8 hours The administration times were listed as 6 AM, 2 PM, and 10 PM. On 5/26/24 at 10 PM, the MAR indicated, Not administered: Drug/ Item unavailable On 5/27/24 at 6 AM the MAR indicated, waiting for delivery MD aware During a telephone interview on 10/10/24, at 12:46 PM, Family Member (FM) 1 stated resident 1 had a superbug infection that was resistant to all antibiotics. FM 1 further stated Cefiderocol was started at the hospital and should have been continued at the facility. FM 1 stated Resident 1 ' s admission to the facility was dependent on the facility being able to provide the antibiotic. During a telephone interview with a facility pharmacy representative on 10/11/24, at 4:06 PM, the Pharmacist (PharmD) stated the facility had price points for managed care insurances and prior approval was required from the Director of Nurses (DON) before they could fill the prescriptions for medications above those price points. The PharmD stated the pharmacy did not receive the infusion order request for Resident 1's Cefiderocol until 5/27/24. A review of a pharmacy document titled, INFUSION THERAPY ORDERS, indicated, Drug : Fetroja Frequency: every 8 hours Duration of therapy: 5 days DON approved 5/27/24 0952 [9:52 AM] A review of Resident 1 ' s Resident Progress Notes, dated 5/27/24, at 10:56 AM, indicated, I spoke with [pharmacy] regarding atb [antibiotic] iv, this writer faxed over DON approval, as well as iv infusion order sheet. This writer spoke to pharmacist about missed doses. Pharmacist assured this writer to monitor resident. If symptoms worsen, notify md [medical doctor] During an interview on 10/11/24, at 2:52 PM, the DON stated during the admission process there were 555713 Page 3 of 5 555713 10/11/2024 Meadowood A Health and Rehabilitation Center 3110 Wagner Heights Road Stockton, CA 95209

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some certain medications the facility ensures are available prior to admission. The DON confirmed the purpose of the admission prescreening process was to determine if the facility could meet the needs of the resident prior to accepting the resident into their care. b. A review of Resident 1 ' s MAR indicated, SUMatriptan [also known as Imitrex and is used for migraine headaches] Pen injector Amount to Administer: 0.5 mL [milliliters-a unit of measurement] FOR HEADACHE INJECT UNDER THE SKIN AT FIRST SIGN OF MIGRAINE. MAY REPEAT AFTER ONE HOUR The start date was 5/26/24. A review of Resident 1 ' s clinical record, Resident Progress Notes, dated 5/27/24, at 11:42 AM, indicated, Spoke with [Pharmacy staff] at 1138 [11:38 AM] regarding out of stock sumatriptan for migraine. Received notice medication is temp [temporarily] out of stock and will send as soon as available. [Pharmacy staff] verbalized if resident is able to take oral medications, we can use with a dr [doctor] order change. A review of Resident 1 ' s MAR dated 5/28/24, at 4:39 AM, indicated, medication administration as hydrocodone-acetaminophen [ Norco, narcotic pain reliever] tablet MODERATE-SEVERE PAIN Pain 7/10 [moderate pain level] PRN [as needed] reason : Pain Comment: headache. A review of Resident 1 ' s clinical record, Resident Progress Notes, dated 5/28/24, at 6:49 AM, indicated, Norco 1 tab given for headache but was not effective. [family member] called at around 0400 [4 AM] and spoke to Ln [licensed nurse] regarding about pt ' s order of Imitrex [sumatriptan] for headache. [family member] claims she has discussed the patient ' s Imitrex order change to a pill form with the nurses on May 27th, during the morning shift called Ccap [physician contact number] to request Imitrex in pill form and d/c [discontinue] injection spoke to PT [patient] around 0600 [6AM] and she agreed to get the injection. LN called [pharmacy]said they would deliver the injection as soon as possible. A review of Resident 1 ' s clinical record, Resident Progress Notes, dated 5/28/24, at 6:52 AM, indicated, received a Call back order From Dr. to give Imitrex 50mg [milligram-a unit of measure] 1 tab [tablet] now if symptoms worsen or pt became unstable then call 911. A review of Resident 1 ' s MAR for May 2024, indicated, sumatriptan tablet. Amount to Administer 1 tab for headache. On 5/28/24 at 9 AM, the MAR indicated, Not Administered : Drug /Item unavailable Pain scale : 6 [moderate pain] unavailable, follow up with pharmacy today. A review of Resident 1 ' s clinical record, Resident Progress Notes, dated 5/28/24, at 2:28 PM indicated, pt c/o [complaint of] headache 5/10 [moderate pain] requested sumatriptan for headache. Refused injection stated that she wanted pill form, notified MD [medical doctor] . During a telephone interview and concurrent record review on 10/15/24, at 10:09 AM, the DON confirmed the documentation indicated the LN was aware on 5/27/24 that sumatriptan could be supplied by the pharmacy in tablet form if an order was received from the MD. The DON further confirmed there was no documentation to indicate the MD was informed of the request on 5/27/24. The DON stated it was her expectation that the nurse would have informed the MD of the request on 5/27/24. The DON confirmed the narcotic administered for Resident 1 ' s headache pain was ineffective. The DON stated there was the potential for Resident 1 to have unrelieved pain when the sumatriptan was not available to treat her headache. 555713 Page 4 of 5 555713 10/11/2024 Meadowood A Health and Rehabilitation Center 3110 Wagner Heights Road Stockton, CA 95209

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of a facility policy titled, Admissions to the facility, revised 3/4/02, indicated, Our facility will admit only those residents whose medical and nursing care needs can be met. The objectives of our admissions policies are to. Admit residents who can be adequately cared for by the facility. A review of a facility policy titled, MEDICATION SHORTAGES, dated 2007, indicated, The facility nurse must make every effort to ensure that a medication ordered for the resident is available to meet their needs .Nursing staff shall, if the shortage will impact the patient ' s immediate need of the ordered product. Notify the attending physician of the situation. Obtain a new order, Notify the pharmacy of the replacement order. 555713 Page 5 of 5