Health inspection·January 5, 2023

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure two of 12 final sampled residents (Residents 16 and 17) and one nonsampled resident (Resident 4) remained free from accident hazards. * The facility failed to ensure the residents' side rails were padded as ordered by the physician and as care planned. These failures posed the risk for the residents to become entrapped or injured by the side rails. Findings: Review of the FDA issued safety alert titled Entrapment Hazards with Hospital Bed Side Rails showed the residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. Inappropriate positioning or other care related activities could contribute to the risk of entrapment. 1. On 1/3/23 at 0911 hours, Resident 4 was observed lying in bed with four full side rails elevated. Three side rails were observed padded; however, the upper left side rail was not padded. Medical record review for Resident 4 was initiated on 1/3/23. Resident 4 was readmitted to the facility on [DATE]. Review of Resident 4's Care Order/Instruction dated 7/20/17, showed to implement padded full side rails to prevent fall/injury secondary to seizure disorder with recurrent seizure activities and the behavior of bouncing back and forth while sitting in bed. Review of Resident 4's plan of care showed a care plan problem revised date 1/3/21, addressing the resident's risk for fall/injury, attempting to get out of the bed by scooting to the end of the bed, and found sitting at the edge of the bed. The interventions were to pad all of the side rails. On 1/3/23 at 1048 hours, Resident 4 was observed sitting in bed rocking back and forth. Four full side rails were elevated with only three side rails padded; the upper left side rail was not padded. On 1/3/23 at 1052 hours, an interview was conducted with RN 1. RN 1 verified the findings and stated all the side rails had to be padded to prevent Resident 4 from injuring herself since she had Page 1 of 8 555883 555883 01/05/2023 West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804

F 0689 seizure disorder and moved around in bed. Level of Harm - Minimal harm or potential for actual harm 2. On 1/3/23 at 0912 and 1052 hours, Resident 16 was observed lying in bed with four full side rails elevated. Three side rails were observed padded; however, the upper left side rail was not padded. Residents Affected - Few Medical record review for Resident 16 was initiated on 1/3/23. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's Care Order/Instruction dated 9/7/22, showed to implement four padded side rails for seizure precaution and poor trunk control. Review of Resident 16's plan of care showed a care plan problem dated 1/10/22, addressing the resident's risk for fall/injury. The interventions included to pad the four elevated side rails due to seizure activity. On 1/3/23 at 1052 hours, an interview was conducted with RN 1. RN 1 verified the findings and stated all the side rails had to be padded to prevent Resident 16 from injuring herself since she moved around in bed. 3. On 1/3/23 at 0904 and 1058 hours, Resident 17 was observed lying in bed with four full side rails elevated. Three side rails were observed padded; however, the lower left side rail was not padded. Medical record review for Resident 17 was initiated on 1/3/23. Resident 17 was readmitted to the facility on [DATE]. Review of Resident 17's Care Order/Instruction dated 12/29/22, showed to implement padded bilateral upper side rails for safety secondary to seizure disorder and to aid in bed mobility. Review of Resident 17's plan of care showed a care plan problem dated 12/13/22, addressing the resident's risk for fall/injury. The interventions included to implement four padded side rails. On 1/3/23 at 1105 hours, an interview was conducted with LVN 3. LVN 3 verified the findings and stated all the side rails had to be padded. 555883 Page 2 of 8 555883 01/05/2023 West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804

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 medical record review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 6.9%. Residents Affected - Few * One of four licensed nurses (RN 2) failed to ensure Resident 11 received the correct doses of medications administered via GT. This failure had the potential for the resident to experience decreased drug efficacy. Findings: Medical record review for Resident 11 was initiated on 1/4/23. Resident 11 was admitted to the facility on [DATE], with a GT. On 1/4/23 at 0958 hours, an observation of the medication administration for Resident 11 was conducted with RN 2. The following medications were administered via GT to Resident 11: - Keppra (for seizure control) 500 mg/5 ml solution two solution containers; - lacosemide (for seizure control) syringe 200 mg (50 mg/5 ml) four syringes (5 ml each syringe); - clonazepam (for seizure control) 1 mg one tablet; - Thera M plus (supplement) one tablet; - Eliquis (a blood thinner medication that reduces blood clotting) 2.5 mg one tablet; - culturelle (probiotic supplement) one capsule; - lansoprazole (stress ulcer prevention) 30 mg one capsule; - bromocriptine (for post traumatic brain injury [an injury that affects how the brain works] treatment to improve wakefulness) 2.5 mg two tablets; - propranolol (medication for high blood pressure) 10 mg one tablet; - vitamin D3 (supplement) 25 mcg 1000 IU two tablets; and - Pro-Stat (supplement) sugar-free liquid 30 ml; RN 2 was observed crushing medications and putting the crushed medications in separated medicine cups. RN 2 placed the liquid medications in separated medicine cups. RN 2 administered each medication one by one via the GT to Resident 11 and flushed the GT with 20 ml of water with each administration. However, after administering the medications via the GT, there were significant amounts of crushed medications left in two medication cups (Thera M plus and bromocriptine). During a follow-up interview with RN 2 after administration of the medication, RN 2 verified the leftover medications were from the medications administered to Resident 11. RN acknowledged to make 555883 Page 3 of 8 555883 01/05/2023 West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804

F 0759 Level of Harm - Minimal harm or potential for actual harm sure the complete dose of medication was given, put additional water to the medication cup, make sure crushed medication was dissolved, and medication cup was clear. LVN 2 acknowledged two of Resident 11's medication cups had significant crushed medication residue and Resident 1 did not receive the full dose of his medications. Residents Affected - Few 555883 Page 4 of 8 555883 01/05/2023 West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview, and facility document review, the facility failed to ensure the menu was followed for three out of three residents on a pureed diet. Residents Affected - Few * The [NAME] failed to follow the recipe for the preparation of mashed potatoes. This posed the risk of the residents' nutritional needs not being met. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 1/3/23, showed three residents in the subacute unit received mechanically altered diets including pureed and all chopped foods. Review of the facility's recipe for mashed potatoes showed to mix 5.25 quarts of water with 2.375 pounds of dry potato granules. On 1/4/23 at 1041 hours, an observation and concurrent interview was conducted with the Cook. The [NAME] stated he was preparing the mashed potatoes. The [NAME] measured one gallon (equivalent to four quarts) of hot water and poured it into a container. The [NAME] then poured an unmeasured amount of the dry potato granules directly from its packaging into the water. The [NAME] verified he did not measure or weigh the dry potato granules as per the recipe, and just added enough so the mixture was not too thick or too runny. On 1/4/23 at 1155 hours, an interview and concurrent facility document review was conducted with the Food Service Supervisor. The Food Service Supervisor stated the recipe yielded 50 portions, but the [NAME] should have reduced the amount of the ingredients while maintaining its ratio to follow the recipe. On 1/5/23 at 0837 hours, an interview was conducted with the RD. The RD verified the [NAME] should have followed the recipe to ensure standardized portion sizes and the nutritive values of each portion. 555883 Page 5 of 8 555883 01/05/2023 West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. Residents Affected - Few * The facility failed to ensure the resident refrigerators/freezers were only used for resident foods. This had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the facility's P&P titled Refrigerators/Freezers: Care of dated 12/15/22, showed resident refrigerators are used only for resident foods. Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility and dated 1/3/23, showed three residents in the subacute unit received foods prepared in the kitchen. On 1/3/23 at 0810 hours, during the initial tour of the kitchen with the Food Service Supervisor, an employee's iced coffee was observed stored inside the resident's freezer. The Food Service Supervisor verified employee foods were not supposed to be stored in the resident refrigerators or freezers to prevent cross contamination. 555883 Page 6 of 8 555883 01/05/2023 West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804

F 0842 Level of Harm - Potential for minimal harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record for one of the 12 sampled residents (Resident 8) was accurately maintained. * Resident 8's medical record contained other residents' (Residents 4 and 7) documents. This failure put the resident at risk for error in medical care and delays in medical treatment. Findings: Review of Resident 8's medical record was initiated on 1/3/23. Resident 8 was admitted to the facility on [DATE]. On 1/4/23 at 1453 hours, review of Resident 8's medical record was initiated. However, Resident 7's Interdisciplinary Plan of Care Conference sheet with summary dated 12/13/22 and Resident 4's Interdisciplinary Plan of Care Conference sheet dated 12/20/22, were found in Resident 8's medical record under the IDT tab. On 1/4/23 at 1502 hours, a concurrent interview and Resident 8's medical record review was conducted with the Clinical Coordinator. The Clinical Coordinator verified Resident 7's Interdisciplinary Plan of Care Conference sheet with summary dated 12/13/22 and Resident 4's Interdisciplinary Plan of Care Conference sheet dated 12/20/22, were filed in Resident 8's medical record. On 1/5/23 at 1340 hours, an interview with the DON was conducted. When asked if the documents of Residents 4 and 7 were supposed to be in Resident 8's medical record, the DON stated only the medical records that belonged to the resident were supposed to be in that resident's medical record. 555883 Page 7 of 8 555883 01/05/2023 West Anaheim Medical Center D/P Snf 3033 W Orange Ave Anaheim, CA 92804

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Potential for minimal harm Based on interview and facility document review, the facility failed to ensure the QAA Committee had met at least quarterly to fulfill the committee's responsibilities to identify and correct quality deficiencies effectively. This failure posed the risk of not identifying problem prone areas and implementing effective changes to ensure resident safety and quality. Residents Affected - Some Findings: On 1/5/23 at 1010 hours, a concurrent interview and review of the QAPI process was conducted with the DON. The DON verified the QAA Committee had not met quarterly for the past year. The last QAA meeting was held on 8/11/21. 555883 Page 8 of 8