Health inspection·June 30, 2025

F689 42 CFR §483.25(d) Accidents. The facility must ensure that – (1) The resident environment remains as free of accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. 22 CCR § 72311. Nursing Service- General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (A) Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission. (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. … (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. 22 CCR § 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. An unannounced visit was conducted by California Department of Public Health on 5/13/2025, at 10:15 AM, to investigate a facility reported incident (FRI) regarding an allegation of an unusual occurrence that a resident (Resident 1) was found unresponsive on 5/12/2025 around 6:00 AM and sent to General Acute Care Hospital (GACH) at 6:20 AM, due to medication intoxication. The facility failed to provide treatment and services to attain the highest practicable mental and psychosocial well-being for Resident 1 who was diagnosed with depression, anxiety (a feeling of fear, dread, and uneasiness), and borderline personality disorder (a mental health condition that affects the way people feel about themselves and others, making it hard to function in everyday life) and who was identified as being danger to self and others (DTSO) on 4/28/2025. The facility failed to: 1. Ensure a 1:1 sitter (one to one nursing or observation care to an individual patient) intervention was put in place for Resident 1 who refused to be sent to GACH on 4/28/2025 due to DTSO. 2. Monitor and document Resident 1’s behavior of verbalizing possibly hurting self or other after the resident was identified to be danger to self and to others on 4/28/2025. 3. Develop and implement a care plan to address Resident 1’s refusal to be sent to GACH on 4/28/2025 in accordance with the physician’s order. 4. Ensure additional follow up and intervention was developed for Resident 1 to ensure Resident 1’s safety and prevent injury and harm to self or to others after resident refused psychiatrist consultation on 5/8/2025. 5. Develop and implement a care plan when Resident 1 was identified to be DTSO on 4/28/2025 to ensure the resident’s safety and security and prevention of injuries. 6. Provide a safe environment by ensuring Resident 1 did not possess an opened 1.5 Liters bottle of Wine 1 and eight medication bottles from Pharmacy 2 (outside pharmacy) labeled with Resident 1’s name while the resident was residing in the facility in accordance with the facility’s policy titled “Restricted Item /Contraband”. As a result, on 5/12/2025, at 5:20 AM, Resident 1 was found unresponsive by Licensed Vocational Nurse (LVN 1) with two (2) opened prescription plastic containers of doxepin (medication to treat anxiety or depression - unknown dosage) and 1 bottle of ondansetron (medication used to prevent nausea and vomiting- unknown dosage). Resident 1 was sent to GACH via 911 (the telephone number used to reach emergency medical, fire, and police services) and was assessed in GACH’ s Emergency Room (ER) with Glascow Coma Scale (GCS- neurological assessment tool used to evaluate a patient’s level of consciousness) score of 3 (indicating a deep comatose state). Resident 1 was intubated (a process where healthcare professional inserts a tube to help the patient to breath) for poor GCS and was admitted to GACH’s Intensive Care Units (ICU) from 5/12/2025 to 5/14/2025. Resident 1’s urine toxicology (screen analyzes a urine sample to identify the presence of drugs or other chemicals) report indicated Resident 1 was positive for tricyclic antidepressant (TCA). A review of Resident 1’s Admission Record indicated the facility admitted Resident 1, a 35-year-old-female, on 11/14/2024, with diagnosis which include depression, anxiety, and borderline personality disorder. A review of Resident 1’s Minimum Data Set (MDS, resident assessment tool), dated 2/1/2025, indicated Resident 1 was assessed to be cognitively intact. The MDS also indicated Resident 1 required set up or clean up assistance (helper set up or cleans up; resident complete the activity) on eating, oral hygiene, personal hygiene. A review of Resident 1’s progress notes dated 4/28/2025, at 10:45 PM, indicated Resident 1 stated, “the facility is a shithole because the people in the facility make it a shithole. It should have been burned down in the fire so all of us suffering from this dick could have somewhere better.” The progress notes also indicated an order to transfer the resident to hospital for DTSO. A review of Resident 1’s “Order sheet” dated 4/28/2025 indicated, “notes: schedule for psychiatrist and psychologist consult. Frequency: one time daily for one day starting 4/28/2025.” A review of Resident 1’s “Physicians Order Sheet” print date on 5/13/2025 indicated, “Transfer to acute hospital: transfer resident due to danger to self and others, order date 4/28/2025”. A review of Resident 1’s medical records from 4/28/2025 to 5/11/2025, did not contain any documented evidence that Resident 1 was transferred to GACH due to DTSO. A review of Resident 1’s progress notes dated 5/12/2025, at 9:36 AM, indicated at 5:20 AM License Vocational Nurse (LVN 1) went to Resident 1’s room to check on the resident and LVN 1 found Resident 1 unresponsive, with pulse and breathing normal. The progress notes also indicated 911 transferred Resident 1 to GACH ER for further evaluation. A review of Local Police D[LP1][RM2]epartment (LPD) report dated 5/12/2025 indicated that on 5/12/2025, at approximately 10:17 AM, LPD were dispatched to the facility to respond to a possible overdose. The LPD report indicated Resident 1 was unresponsive and was sent to GACH. LPD report also indicated according to the interview with ADM that the ADM received a text from the charge nurse indicating Resident 1 was not waking up possibly due to the medications and alcohol the resident may have consumed. The report also indicated Resident 1 was taken to the GACH on 5/12/2025, at approximately 6AM.According to the interview with ADM, the medications found at Resident 1’s bedside were not provided by their facility (but from Pharmacy 2) and belonged to and was labeled under Resident 1’s name. The LPD report also indicated the following medications (total of 8 bottles) were found in the resident’s belongings: 1. One bottle of ondansetron. 2. Two bottles of Doxepin. 3. One empty bottle of Doxepin (amount and dosage not indicated) 4. One bottle of Klonopin (medicine used to control seizures. Amount and dosage not indicated) 5. Two empty bottles of Klonopin (amount and dosage not indicated) 6. Blue and tan pills (did not indicate name of medication- amount). A review of the facility’s Final Investigation Summary Report submitted to the surveyor on 5/16/2025, indicated that LPD 1 came to the facility at approximately 11:00 AM (date not specified) and searched Resident 1’s room and LPD found “pill bottles (bottle of medications) inside a shopping bag” and a 1.5 Liter bottle of Wine 1. The report also indicated the facility found the following items in Resident 1 belongings on 5/12/2025: 1. Crumpled receipt from Pharmacy 2 shopping bag and the receipt indicated Wine 1 was purchased from Pharmacy 1 on 5/9/2025, at 5:46 PM. 2. Bottle of medications from Pharmacy 2 labeled with Resident 1’s name: Klonopin 0.5 milligrams (mg) which was found empty; 15 pieces of Dilaudid 2 mg; Zuplenz 4 mg sachet with expiry date of 12/2020; 52 capsules of doxepin 100 mg and 10 tablets of Ondansetron 8 mg with expiry date of 3/2025. A review of Resident 1’s GACH records dated from 5/12/2025 to 5/20/2025 indicated that Resident 1 was admitted at GACH from 5/12/2025 and was discharged to home with Resident 1’s family on 5/20/2025. The GACH record indicated that on 5/12/2025 Resident 1 was brought to GACH’s ER with chief complaint of altered mental status at SNF next to empty pill bottles (name of medication not specified) and Resident 1 with GCS of 3. The GACH record also indicated Resident 1 was brought in by ambulance after the resident was found in the facility sleepy and obtunded this morning (5/12/2025). The GACH record also indicated per paramedic’s report that Resident 1 was found next to alcohol bottles (type not specified) and a bag of pills (not specified) that were unknown and possibly there was a bottle of Klonopin. A review of the same Resident 1’s GACH records dated from 5/12/2025 to 5/20/2025 indicated, Resident 1 was intubated for poor GCS. The GACH records also indicated Resident 1 had “intentional TCA overdose +/- (with or without) Klonopin”. The GACH records indicated, Resident 1 was admitted in GACH’s ICU from the ER, then downgraded option to Medical Surgical Unit (MSU- a specific area where patients receive care for a variety of medical/ surgical conditions and less critical patient than in ICU) on 5/14/2025. During an interview on 5/14/2025, at 7:05 AM, LVN 3 stated that on 5/12/2025, at around 5AM, Resident 1 was unresponsive and LVN 3 tried to wake Resident 1 for 10 minutes, but Resident 1 was not responding. LVN 3 stated, Resident 1 was laying across the bed horizontally and snoring loud. LVN 3 stated LVN 3 saw 2 opened prescription plastic containers of doxepin (unknown dosage) and 1 bottle of ondansetron (unknown dosage). LVN 3 stated the medications were not dispensed from the facility’s pharmacy (Pharmacy 1). LVN 3 stated the residents are not allowed to have medications from outside the facility and all medications should be prescribed by the primary physicians and medication supplies should be coming from Pharmacy 1. During a concurrent interview and record review on 5/14/2025, at 7:25 AM, with LVN 1, Resident 1’s progress notes dated 5/12/2025 was reviewed. LVN 1 stated that she started her shift on 5/11/2025, at around 11:30 PM, making rounds and did not check on Resident 1 until 5/12/2025 around 5:20 AM. LVN 1 stated at 5:20 AM Resident 1 was laying across the bed, snoring, and unresponsive to stimuli. LVN 1 stated, Resident 1 had 2 opened prescription plastic containers of doxepin and 1 bottle of ondansetron on the resident’s bedside table both labeled under Resident 1’s name and from Pharmacy 2. LVN 1 stated, Resident 1 was transferred to GACH ER via 911 around 6 AM and that police came approximately 4 to 5 hours after. LVN 1 also stated that LPD searched Resident 1’s belongings and found four (4) additional plastic containers/ bottles of prescription medication labeled under Resident 1’s name from Pharmacy 2. LVN 1 stated, the 4 additional plastic bottles of prescription medications were as follows: Klonopin, and Clonazepam (another name for Klonopin) were inside the plastic bag with a bottle of open Wine 1. LVN 1 stated, LVN 1 was unable to recall the dosage of these medications. During an interview on 5/14/2025, at 10:16 AM, Registered Nurse Supervisor (RNS 1) stated all medications from an outside pharmacy such as Pharmacy 2 were not allowed. It was for residents’ safety. RNS 1 stated only Pharmacy 1 (facility’s own pharmacy) can deliver medications for each resident. RNS 1 stated the medications, which are in a bubble pack are delivered once a month by Pharmacy 1. RNS 1 stated the medications are for a 30 day supply for each resident and are administered by the licensed nurses.[LP3][RM4] During an interview on 5/14/2025, at 12 PM with LVN 2, LVN 2 stated the facility staff do not check residents’ belongings, and the residents usually present whatever they have. During a concurrent interview and record review on 5/14/2025, at 3:30 PM with LVN 2, Resident 1’s medical chart dated from 4/28/2025 to 5/13/2025 was reviewed. There was no documented evidence that the facility monitored Resident 1 after being assessed as DTSO and when Resident 1 refused to be transferred to GACH. LVN 2 stated there was no monitoring and documentation from 4/28/2025 to 5/11/2025 regarding resident’s danger to self and others on the resident’s progress notes. LVN 2 also stated Resident 1 did not have care plan developed to address Resident 1’s refusal to be transferred to GACH on 4/28/2025. During a concurrent interview and record review on 5/14/2025 at 3:35 PM with LVN 2, Resident 1’s progress notes dated 5/8/2025 at 5:09 PM, and Resident 1’s medical chart dated from 5/9/2025 to 5/13/2025 were reviewed. The progress notes dated 5/8/2025 indicated, “offered Psychiatric consult but declined and stated that she (Resident 1) had her own psychiatrist.” In addition, there was no documented evidence that the facility made a follow up and provided additional interventions after Resident 1 refused psychiatrist consult. LVN 2 stated there was no additional follow up and intervention made for Resident 1 to ensure Resident 1’s safety and prevent injury and harm to self or to others after Resident