Heritage Rehabilitation Center
HERITAGE REHABILITATION CENTER in TORRANCE, CA — inspection on June 13, 2024.
Found 15 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a record review of the facility's policy and procedure (P&P) titled Answering the Call Light (undated) indicated, The purpose of this procedure was to respond to the resident's requests and needs.
When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.
Some residents may not be able to use their call light. Be sure you check these residents frequently.
Report all defective call lights to the Nurse Supervisor promptly.
Answer the resident's call as soon as possible. Be courteous in answering the resident's call.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
During an interview on 6/12/2024, at 2:43 p.m., with Social Service Director (SSD), SSD stated she spoke to Resident 25 yesterday evening after Licensed Vocational Nurse (LVN 8) told her about Resident 25's complaint of being cold in her room. SSD stated Resident 25 would not feel comfortable and might lose sleep if the temperature of the room is too cold for her.
During an interview on 6/13/2024, at 3:31 p.m., with the Director of Nursing (DON), the DON stated she was not informed of Resident 25's complaint of being cold in her room.
The DON stated cold room would cause discomfort to the resident.
During a review of facility's policy and procedure(P&P) titled Homelike Environment revised 2/2021, indicated the facility's staff and management will maximize the characteristics of the facility that will reflect a personalized and homelike setting including a comfortable and safe temperature to the residents.
The P&P indicated the staff will provide person-centered care that emphasizes the resident's comfort, and personal needs or preferences.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
symptom, the type of restraint and the period of time for the use of restraint.
The P&P indicated a
observation, range of motion and repositioning.
The P&P indicated restrained individuals will be
or total restraint elimination.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
During a review of Resident 50's admission Record, Resident 50 was admitted to the facility on [DATE] with a diagnosis of major depressive disorder.
During a review of Resident 50's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 4/5/2024, indicated Resident 50 was assessed in needing maximal assistance for all activities of daily living (ADL).
During a review of Resident 50's Physician Order Summary Report, Resident 50 was prescribed Quetiapine Fumarate (medication used to treat certain mental/mood disorders) for psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) manifested by hostility (emotionally charged aggressive behavior) and agitation (unable to relax and be still).
During a review of the PASARR I, dated 4/24/2024, the PASARR I indicated a negative level I screen.
The PASARR I indicated Resident 50 has a serious mental disorder (conditions that affect your thinking, feeling, mood, and behavior).
During an interview on 6/13/2024 at 10:14 a.m., with the medical records director (MRD), the MRD stated she was responsible for overseeing the PASARR and ensuring it was done correctly. MRD stated Resident 50 has a negative PASARR I because she has dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and that was what she was taught.
During an interview on 6/13/2024 at 3:20 p.m., with the Director of Nursing (DON), the DON stated that if a resident has a mental disorder and was prescribed medications for the mental disorder, the PSARR I should reflect as positive.
The DON stated the PASARR I should have been corrected and was missed by us.
The DON stated any resident with a mental disorder should be evaluated accurately so they could be treated and cared for correctly.
During a review of the facility's policy and procedure (P&P) titled, admission Criteria, revised January 2024, the P&P indicated If the Level I screen indicates that the individual may meet the criteria for a mental disorders (MD), intellectual disabilities (ID- when limitations in your mental abilities affect intelligence, learning, and everyday life skills), or related disorders (RD), he or she is referred to the states PASARR representative for the Level II (evaluation and determination) screening process.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
During a review of the facility's undated policy and procedure (P/P) titled, Care Plan - Comprehensive, the P/P indicated comprehensive care plans are developed and maintained for each resident that identified the highest level of functioning the resident may be expected to attain.
The P/P indicated the comprehensive care plan was developed for each resident and included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs.
The P/P indicated each resident's comprehensive care plan was designed to .identify the professional services that are responsible for each element of care, aid in preventing or reducing declines in the resident's functional status and/or functional levels, enhance the optimal functioning of the resident by focusing on a rehabilitative program, and reflect currently recognized standards of practice for problem areas and conditions.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
purpose of this procedure was to exercise the resident's joints and muscles.
The following
- The date and time that the exercises were performed.
- The name and title of the individual(s) who performed the procedure.
- The type of ROM exercise given.
- Whether the exercise was active or passive.
- How long the exercise was conducted.
- If and how the resident participated in the procedure or any changes in the resident's ability to
- Any problems or complaints made by the resident related to the procedure.
- If the resident refused the treatment, the reason(s) why and the intervention taken.
- The signature and title of the person recording the data.
participate in the procedure.
CROSS REFERENCE TO F-F725
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
During a review of the facility's P&P titled, Weight Assessment and Intervention dated 9/2008, indicated, Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing.
Verbal notification must be confirmed in writing.
The Dietician will review the unit weight record by the 15th of the month for follow individual weight trends over time.
During a review of the facility's P&P titled, Enteral Nutrition, dated 11/2018, the P&P indicated, The dietician with input from the provider and nurses: estimate calorie, protein, nutrients, and fluid needs.
Determine whether the resident's current intake is adequate to meet his or her nutritional needs.
The dietician monitors residents who are receiving enteral nutrition and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of enteral feedings.
During a review of the facility's P&P titled, Nutritional Assessment, [undated], indicated, The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that place the resident at risk for impaired nutrition.
During a review of the facility's P&P titled, Nutrition Impaired/Unplanned Weight Loss-Clinical Protocol, [undated], indicated, The Physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition.
Such monitoring may include evaluating the care plan to determine if the interventions are being implement and whether they are effective in attaining the established nutritional and weight goals.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
During an interview on 6/13/2024, 2:04 p.m., CNA 5 stated every time she would clean and change Resident 73 after a bowel movement, the resident would moan and cry. CNA 5 stated Resident 73 would also moan during pressure ulcer treatment.
During a review of Resident 73's Care Plan titled Potential for altered comfort evidenced by grimacing or moaning related to a Stage 4 pressure ulcer to the sacrum, bilateral knee osteoarthritis and pancreatic mass (tumor that forms in the cells of pancreas), dated 4/20/2023, the goal for Resident 73 was to be comfortable.
The Care Plan's interventions included to identify frequency, location, quality, onset, and manner of expressed pain and administer medication as ordered.
During a review of Resident 73's Care Plan titled, Resident has a Stage 4 sacral pressure ulcer on admission, initiated on 10/30/2023 indicated one of the interventions was to assess pain and discomfort at site of the altered skin area.
During a concurrent interview and record review of Resident 73's Physician Order on 6/13/2024, at 3:31 p.m. with Director of Nursing (DON), the DON confirmed the physician order for Tylenol 325 mg two tablets for pain relief did not include the pain parameters, however, Resident 73 had an order to monitor the intensity of pain using numerical pain rating scale.
The DON stated pain level was not assessed properly and Resident 73's pain was not managed effectively during pressure ulcer treatment.
The DON stated Resident 73 should be assessed for pain during and after pressure ulcer treatment.
The DON stated if the resident was experiencing pain by screaming and moaning, the pressure ulcer treatment should be stop, the staff should have assessed the resident for pain, addressed the pain if pain was present, called Resident 73's physician to notify about the presence of pain.
The DON stated Resident 73 had experienced undue suffering which could have been prevented if the resident was assessed properly for pain management.
During a review of facility's policy and procedure (P&P) titled Pain Assessment and Management, undated, the P&P indicated to observe the resident during rest and movement for physiologic and behavioral (non-verbal) signs of pain.
The P& P indicated possible behavioral signs of pain are verbal expressions such as groaning, crying, screaming, facial expressions such as grimacing, frowning, behavior such as resisting care, irritability, or depression.
The P&P indicated to review resident's treatment record to identify any situations or interventions where an increase in the resident's pain may be anticipated such as treatment like wound care or dressing changes.
During a review of facility's P&P titled Pressure Ulcer Treatment, undated, the P&P indicated to review the resident's care plan to assess for any special needs of the resident.
The P&P indicated for residents who had a Stage 4 Pressure Injury one of the guidelines was to manage pain during wound care.
According to a review the article titled The Symptoms of Pain with Pressure Ulcer: A
Review of the Literature, dated 5/2008 on website for Wound Care Leading Management and Prevention, pain is an issue in persons with pressure ulcers, measuring and managing pain will become more important for effective care with an aging population at risk for pressure ulcer development. https://www.hmpgloballearningnetwork.com/site/wmp/content/the-symptom-pain-with-pressure-ulcers-a-review-literature
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
the facility provided adequate staffing on each shift to ensure the resident's needs and services were
CROSS REFERENCE TO F-F688
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
During a review of Resident 239's physician order of Norco 10-325 mg dated 6/7/2024 at 12:13 p.m. indicated to give 1 tablet by mouth every 8 hours as needed for moderate to severe pain.
During a review of the Narcotic and Hypnotic Record for Resident 239's Norco 10-325 mg indicated there was one dose issued on 6/1/2024 at 9:13 a.m.
Norco narcotic record 6/12/24 at 6 AM.
During a concurrent interview and record review on 6/12/2024 at 3:03 p.m., with the DON, reviewed Resident 239's eMAR.
The DON stated there was no documentation in the eMAR for the following doses as indicated on the Narcotic Record: 6/7/2024 at 6 a.m., and 6/12/2024 at 6 a.m.
The DON stated the administering nurses did not document the administrations of these two doses.
During a review of the facility's P&P titled Oral Medication Administration (undated) indicated, .
Return to the Medication Cart and document medication administration with initials in appropriate spaces on the MAR.
During an interview on 6/12/2024 at 9:54 a.m., the ADON stated the prescriber obtained informed consents for residents' psychotropic uses; when facility got the order, nurses contact resident and/or family member to inform them of such order and verify if they had given consent to receive the psychotropic medications.
During a review of the facility's P&P, Consent Requirements For Psychotherapeutic Medications (undated), indicated .
There is no requirement to obtain a new consent when a dosage change is made .
The facility and nurses are neither responsible to determine that all risks are enumerated and disclosed .The facility is not responsible for obtaining a signature .
During an interview on 6/12/2024 at 10:10 a.m., ADON acknowledged the facility P &P did not match the current regulatory requirements.
During a telephone interview on 6/12/2024 at 3:27 p.m. the facility consultant pharmacist stated the facility was aware of the outdated consent policy and they were in the process of updating the policy.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
Based on observation, interview, and record review, the facility failed to ensure the label of a bubble
bubbles) reflected the current dosage, and/or a change in dosage, for one (1) of 30 sampled residents (Resident 239).
This deficient practice had the potential for medication error.
Findings
During an observation on 6/12/2024 at 2:55 p.m. at the nursing station A medication cart, the Licensed Vocational Nurse (LVN 5) presented a bubble pack belonged to Resident 239.
The pharmacy label on the bubble read: hydrocodone-acetaminophen (potent narcotic for the treatment of pain) 10-325 milligrams ([mg] unit to measure mass), take one tablet by mouth every eight hours for pain management.
During a review of Resident 239's physician orders indicated Norco 10-325 mg, give 1 tablet by mouth every 6 hours as needed (PRN) for moderate to severe pain (pain level 6-10), ordered on 6/7/2024 at 12:13 p.m.
During an interview on 6/12/2024 at 3:03 p.m., the Director of Nursing (DON) stated Resident 239's routine order of Norco had been discontinued and replaced by a PRN order.
The DON stated when there was a change of dosage and the remainder tablets can be used, the nurse should contact the pharmacy and obtain a change of dose sticker to be placed on the bubble pack. -+ During a review of the facility's policy and procedures (P&P) titled Guidelines for Medication Administration (undated) indicated, . If a discrepancy exists, . consult the appropriate resource(s) such as the pharmacist . If label directions are incorrect, the medication nurse is responsible for affixing a direction change sticker. If the Medication Administration Record and the medication labeling do not match, the medication nurse should investigate the discrepancy .
During an interview with the Administrator, Quality Assurance Nurse and the Director of Nursing (DON) on 6/13/2024 at 3:09 p.m., the DON stated not being able to identify systemic issues identified even before the survey.
The QA Nurse and the DON, both stated QAA was supposed to identify systemic issues and address it.
The Administrator acknowledged the facility had opportunities for improvement of all mentioned deficient practices.
During a record review of the facility's policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Program revised 3/2020, the policy indicated This facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents. To provide a means to measure current and potential indicators for outcomes of care and quality of life. To provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators. To reinforce and build upon effective systems and processes related to the delivery of quality car and services. To establish systems through which to monitor and evaluate corrective actions.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
During a review of Resident 3's Minimum Data Sheet (MDS- a comprehensive assessment and care planning tool) dated 5/10/2024 indicated Resident 3 had moderate cognitive impairment (ability to learn, understand, and make decisions) and requires maximum assistance for toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene.
During an observation on 06/10/2024 at 10:48 a.m.,11:45 a.m., 12:47 p.m., and 2:10 p.m., observed Resident 3 nephrostomy tube bag on top of the bed next to the resident parallel to his body.
During an interview on 6/11/2024 at 2:50 p.m., the Director of Staff Development (DSD) stated nephrostomy tube drainage must be below the Resident 3's kidney to prevent reflux (flow backwards) of the urine to prevent infection.
During an interview on 6/13/2024 at 8:54 a.m., the Licensed Vocational Nurse (LVN 4) stated when nephrostomy tube bag was in the same level of the kidney urine does not flow by gravity and can create urine backflow and might lead to infection.
During a review of facility's P&P titled Nephrostomy Tube, Care of(undated), indicated Drainage should be below the level of the kidneys.
056308 06/13/2024
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
During a concurrent observation, interview, and record review on 6/11/2024 at 11:43a.m., with Assistant Director of Nursing (ADON) in the medication storage room at the nursing station A, there was an Emergency Kit ([EKIT] an emergency drug supply) logbook.
Reviewed the logbook and the Emergency Drug Supply Log Sheet with the ADON, the ADON stated licensed nurses document medication taken from the EKIT and the Cubex on the Emergency Drug Supply Log Sheet.
During a review of the Cubex pharmacy transactions on 5/30/2024 indicated, there was a tablet of alprazolam (used to treat anxiety) 0.25 milligrams ([mg] a unit to measure mass) issued for Resident 5 on 5/30/2024 at 3:59 p.m.
During a review of Resident 5's physician orders indicated an order dated 5/30/2024 at 2:28 p.m. for alprazolam 0.25 mg, give 1 tablet by mouth every eight (8) hours as needed for anxiety.
During an interview on 6/11/2024 at 11:45 p.m., ADON stated this issuance of alprazolam was not recorded in the Emergency Drug Supply Log Sheet.
During a review of the facility's policy and procedures (P&P), (undated), indicated .
Cubex .Emergency STAT orders may be retrieved pursuant to the order of a prescriber for emergency or immediate administration to a resident of the facility .
The CUBEX System keeps a complete and accurate record of all users accessing the cabinet .
056308
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056308 B.
Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
The facility failed to:
1.
Ensure the Registered Dietician's ([RD] a health professional who has a special training in diet and nutrition) recommendation to increase Resident 129's enteral (form of nutrition that is delivered into the digestive system as liquid) feeding from 250 milliliter ([ml] unit of measurement) four times per day to 250 ml five times per day totaling 1500 calories ([kCal] energy people get from the food and drink they consume, and the energy they use in physical activity) were followed and provided.
2.Ensure staff monitored Resident 129's weight and reported the resident's five pounds weigh loss to Resident 129's physician and RD in accordance with the care plan titled Risk for Malnutrition (lack of significant nutrients [substance used in the body to function] leading to physical decline).
3.
Ensure the facility's staff informed the RD when Resident 129 had a 9.57 % weight loss from 4/29/2024 through 6/1/2024 for RD to evaluate and make necessary recommendations on Resident 129's enteral feeding formula to provide Resident 129 with a sufficient amount of calories and nutrients to prevent Resident 129's severe weight loss of 9.57 % in 34 days in accordance with the facility's policy and procedure (P&P) titled, Nutrition (Impaired/Unplanned Weight Loss-Clinical Protocol.
4.
Ensure licensed staff followed facility's P&P titled, Weight Assessment and Intervention and immediately notified the Dietician in writing of Resident 129's weight loss of 5% or more since the last weight assessment on 4/29/2024.
5.
Ensure the RD completed Resident 129's full nutritional assessment upon admission to the facility on [DATE] and monitor Resident 129's weight and caloric intake, who was receiving tube feeding nutrition, and makes appropriate recommendations for intervention to enhance tolerance and nutritional adequacy of tube feedings per facility's P & P.
These deficient practiced resulted in Resident 129's severe weight loss of 9.57 % in 34 days and placed Resident 129 at risk for malnutrition, dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake), skin break down, having feelings of depression and hopelessness.
Findings:
056308
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056308 B.
Wing 06/13/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Rehabilitation Center 21414 S.
Vermont Avenue Torrance, CA 90502
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.