**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and services in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) for one of two sampled residents (Resident 1) who had a diagnosis of other sequalae of cerebral infarction (the long-term conditions and complications that result from brain tissue damage due to reduced blood supply), other interval disc (a cushion of cartilage found between the vertebrae (bones) of the spine) lumbar region (the lower back region of your spinal column or backbone), other spondylosis with radiculopathy - lumbar region (a condition where the degenerative changes of spondylosis [osteoarthritis of the spine] lead to compression of spinal nerve roots, resulting in radiculopathy symptoms. Spondylosis itself refers to the general wear and tear of the spine, while radiculopathy is the specific symptom of a pinched nerve) and status post (S/P- underwent surgery) lumbar decompression and fusion (a surgical procedure that addresses lower back pain and nerve compression by removing pressure from the spinal nerves and fusing the vertebrae together to stabilize the spine) posterior (further back position) on 4/14/2025 from General Acute Care Hospital (GACH) by failing to: 1. Ensure Registered Nurse (RN) 1 reviewed and verified with the facility's attending physician (Physician 1) Resident 1's GACH records dated 4/21/2025 and relayed the completed and accurate discharge order from GACH's neurosurgeon (Physician 2- a surgeon specializing in surgery on the nervous system, especially the brain and spinal cord) of Resident 1's Plavix (brand name for clopidogrel- medication to prevent blood clots) 75 milligram (mg, unit of measurement) to start on 4/30/2025 (9 days from the day of admission). 2. Ensure facility provided continuity of care to Resident 1's S/P lumbar decompression and fusion posterior in accordance with MD2's order to start Plavix 75 mg on 4/30/2025 when the facility licensed nurses administered Plavix 75 mg to Resident 1 starting 4/22/2025 to 4/25/2025 (4 days). 3. Ensure Resident 1 was assessed and monitored for signs and symptoms of bleeding/ hematoma (pool of mostly clotted blood that forms in an organ, tissue, or body space)/ hemorrhage (bleeding from a damaged blood vessel) specifically for Resident 1's S/P lumbar decompression and fusion posterior, and Plavix use from 4/22/2025 to 4/25/2025. As a result, Resident 1 had a change of condition (COC) on 4/26/2025 at 1:05 PM, as evidenced by Resident 1 unresponsive to external stimuli (external changes or events that trigger a response in the nervous system. These stimuli can be anything from sights and sounds to smells, tastes, and physical sensations like pain or touch). Resident 1 was transferred to GACH via 911 emergency services (EMS - provides emergency medical care) on 4/26/2025 at 1:30 PM and was admitted to the Emergency Department. Resident 1 underwent Computerized Tomography scan (CT scan - imaging using x-ray technique to create detailed images of the body) of the head in GACH and result showed an acute (sudden) right subdural (occurring between the dura mater [the tough outermost membrane enveloping the brain and spinal cord] and the arachnoid membrane [a thin, spiderweb- like membrane that surrounds the brain and spinal cord] of the brain and spinal cord) hematoma measures 14 millimeters (mm- unit of measurement) in width. The CT scan result also showed there was an adjacent right temporal intraparenchymal (bleeding within the brain tissue [parenchyma] specifically located in the right temporal lobe [one of two brain lobes responsible for processing sensory information, especially sounds, and plays a role in memory, emotional processing, and spatial awareness] of the brain) hematoma measuring 3.7 x 2.8 x 4.2 centimeters (cm- unit of measurement). In addition the CT scan result there was subfalcine (the most common form of intracranial herniation and occurs when brain tissue is displaced under the falx cerebri [a sickle-shaped vertical fold of dura mater that separates the two cerebral hemispheres {one of the two symmetrical halves of the cerebrum, the largest part of the brain} and helps in preventing certain types of brain herniation]), uncal herniation (occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another) and subacute (between acute and chronic) hemorrhage in the left parietal lobe (left side of the brain) measuring 2.7 cm x 2.7 cm. Resident 1 died in GACH on 4/27/2025 at 12:17 AM and Resident 1's immediate cause of death was nontraumatic intracranial hemorrhage (bleeding within the brain tissue that is not the result of head trauma or surgery- can be caused by blood clotting problems. It's a serious condition that can lead to stroke and potentially be fatal). On 5/20/2025 at 3:59 PM, while onsite at the facility, the California Department of Public Health (CDPH) identified an Immediate Jeopardy situation (IJ, a situation in which the providers' noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident) regarding the facility's failure to ensure Resident 1, who had a diagnosis of other sequalae of cerebral infarction, other interval disc lumbar region, other spondylosis with radiculopathy - lumbar region and S/P lumbar decompression and fusion posterior on 4/14/2025 from GACH received treatment and services in accordance with professional standards of practice . The team notified the Administrator (ADM) and Director of Nursing (DON) of an IJ situation on 5/20/2025 at 3:59 PM, due to the facility's failure to: ensure RN 1 reviewed and verified with the Physician 1 Resident 1's GACH records dated 4/21/2025 and relayed the completed and accurate discharge order from Physician 2 of Resident 1's Plavix 75 mg to start on 4/30/2025 (9 days from the day of admission), ensure facility provided continuity of care to Resident 1's S/P lumbar decompression and fusion posterior in accordance with MD2's order to start Plavix 75 mg on 4/30/2025 when the facility licensed nurses administered Plavix 75 mg to Resident 1 starting 4/22/2025 to 4/25/2025 (4 days) and ensure Resident 1 was assessed and monitored for signs and symptoms of bleeding/ hematoma/ hemorrhage specifically for Resident 1's S/P lumbar decompression and fusion posterior, and Plavix use from 4/22/2025 to 4/25/2025. On 5/21/2025 at 6:04 PM, the ADM provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings). While onsite and after the surveyor verified/confirmed the facility's full implementation of the IJ Removal Plan through observation, interview and record review, and determined the IJ situation was no longer present, the IJ was removed onsite, in the presence of the ADM and DON. After the IJ was removed, the surveyor verified that the facility's non-compliance remained at a lower scope and severity (refers to the seriousness of the harm to the residents) of isolated (refers to the deficiencies affecting a very limited number of resident/s), actual harm (means the resident have experienced a negative outcome or injury due to the non-compliance), that was not immediate jeopardy. The IJ Removal Plan dated 5/21/2025, included the following: -On 5/20/2025, the DON and designee provided in-service education to all licensed nurses and direct care staff regarding reviewing and verifying any discrepancies with the ordering physician by clarifying the faxed medication discharge order and the GACH discharge papers that were given to the resident. In addition, clarify medication orders that are missing the start and end dates. -On 5/20/2025, the DON and designee provided in-service education to all licensed nurses and direct care staff regarding monitoring the resident status post-surgery and the use of anticoagulant therapy (using medications to prevent or reduce blood clotting) for potential side effects such as signs/symptoms of bleeding. -On 5/20/2025, the DON and designee provided in-service to the licensed nurses regarding: 1. Review and verify GACH discharge orders with facility's attending physician. 2. Status post-surgery residents with anticoagulant use and signs/symptoms of bleeding. 3. Following GACH discharge orders. Any licensed staff, who were not present, the DON will do in-service education upon returning to work. -Thirty- eight (38) residents were on anticoagulants and were assessed for any signs/symptoms of bleeding, potential side effects of anticoagulant use and black box warning (the most serious type of warning mandated by the U.S. Food and Drug Administration [FDA] for prescription drug labeling) monitoring. -The Registered Nurse (RN) Supervisor will check clinical alerts report daily for any COC and any signs/symptoms of bleeding. -DON, ADON or RN Supervisor/designee will conduct medication reconciliation (the process of comparing a patient's medication orders to all of the medications that the patient has been taking) with the residents GACH discharge orders and admitting orders carried out by licensed nurse. -Starting 5/21/2025, newly admitted residents will have random audits following GACH discharge orders and completion of medication reconciliation. Three (3) residents weekly for four (4) weeks, Then two (2) residents weekly for 2 weeks Then 2 residents a month for two months. Inservice would be given to licensed nurses involved. Findings will be presented in the monthly QAA (Quality Assurance Agency) meeting. -DON implemented a Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) for the following: 1. Review and verify GACH discharge orders with attending physician 2. Use of anticoagulant and its side effects. 3. Following GACH discharge orders. - PIP resulted in DON/ADON doing daily audits in reviewing compliance for following GACH discharge orders, continuity of care, use of anticoagulant and identification of potential adverse side effect (an undesired effect of a drug) of the medication. - The Quality and Safety (QS) RN/Consultant will complete 3 audits weekly on medication reconciliation, the use of anticoagulants, and its side effects for newly admitted residents. -ADM, DON or Designee will submit audit findings to QAA committee monthly for 3 months until compliance is met. -The facility will develop a QAPI-PIP for the use of anticoagulant to be submitted in the next QAA committee meeting on 5/28/2025. -ADM and DON are responsible for implementing, monitoring and evaluating the Plan of Correction (POC). Findings: During a review of Resident 1's admission Record, the admission Record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses that included intervertebral disc displacement (breakdown of one or more disc that separates the bones) in lumbar region (lower back), spondylosis with radiculopathy (herniated [bulging of an organ] cervical discs that press on the spinal nerve roots and cord) and hypertension (high blood pressure). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/26/2025, the MDS indicated Resident 1was severely impaired in cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with eating and oral hygiene but was dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off footwear. During a review of Resident 1's GACH records dated from 4/8/2025 to 4/21/2025, it indicated Resident 1's CT of the brain without contrast (without the use of a special dye. This type of scan is used to detect acute problems like bleeding or to assess the general health of the brain, bone and tissue) was done on 4/8/2025, showed no bleed or large infarct (an area of brain tissue death) in the brain. The GACH records also indicated Resident 1 was diagnosed at GACH with other sequalae of cerebral infarction, other interval disc lumbar region, other spondylosis with radiculopathy - lumbar region and S/P lumbar decompression and fusion posterior on 4/14/2025 in GACH. During a review of Resident 1's facsimile (fax- an exact copy or reproduction of something, often used in the context of transmitting documents electronically or over a phone) GACH Discharge Medication List, dated 4/21/2025, indicated Plavix 75 milligrams (mg - unit of measure) Tab (did not indicate start date). During a review of Resident 1's GACH pended (awaiting completion) discharge orders, dated 4/21/2025, the discharge orders indicated Plavix 75mg Tablet Daily will start on 4/30/2025. During a review of Resident 1's GACH discharge medication list, dated 4/21/2025, the medication list indicated to start Plavix 75mg tablet on 4/30/2025. During a review of Resident 1's Physician Orders at the facility, dated 4/21/2025, the Physician Order indicated Plavix Oral Tablet 75 mg. Give one (1) tablet by mouth one time a day for cardiovascular accident (CVA) prophylaxis (PPX, preventive treatment). During a review of the facility's Pharmacy Records for Resident 1, dated 4/21/2025, the Pharmacy Records indicated Plavix tab 75mg was dispensed (the process of preparing and giving medicine on the basis of a prescription) to the facility. During a review of the Facility's Pharmacy Receipt, dated 4/22/2025, the receipt indicated Resident 1's medication of Plavix Tab 75 mg delivered with 14 tablets. During a review of Resident 1's Care Plan with focus Antiplatelet (medications that prevent blood platelets [cell in the blood that involves in clotting] from sticking together and forming clots. They work by inhibiting certain phases of the blood clotting process, making the blood less sticky and less prone to forming clots in arteries) use related to Clopidogrel Bisulfate (same as Plavix), revised 4/22/2025, the Care Plan indicated resident will be free from signs/symptoms of abnormal bleeding. During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) from the facility, dated April 2025, the MAR indicated Plavix was given to Resident 1 on 4/22/25 to 4/25/2025. During a review of Resident 1's SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 4/26/2025 at 1:05 PM, the SBAR indicated the Resident 1 was unresponsive to external stimuli and was sent to GACH via 911 (time not indicated). During a review of Resident 1's Emergency Department (ED) to GACH admission Record, dated 4/26/2025, the GACH admission Record indicated the Resident 1 went to CT scan of the head and was found to have an acute right subdural hematoma measures 14 mm in width, there was also an adjacent right temporal intraparenchymal hematoma measuring 3.7 x 2.8 x 4.2 cm and these resulted in significant leftward shift (when the natural centerline of the brain is pushed to the left) with 2 cm leftward shift, subfalcine and uncal herniation. The CT scan result also showed subacute hemorrhage in the left parietal lobe (Left side of the brain) measuring 2.7 cm x 2.7 cm. During a review of Resident 1's GACH Discharge summary, dated [DATE] at 12:35 PM, the GACH discharge summary indicated Resident 1 had worsening of mental status requiring intubation (a process where a healthcare provider inserts a tube through a person's mouth or nose, then down into their trachea [airway/windpipe]. The tube keeps the trachea open so that air can get through. The tube can connect to a machine that delivers air or oxygen) and found intracranial hemorrhage (brain bleed) with poor neurological prognosis (a low likelihood of recovery from a neurological condition, with the potential for death, persistent unconsciousness, or severe disability) and progression to brain death. Resident was pronounced dead on 4/27/2025 at 12:17 PM. During an interview on 5/20/2025 at 12 PM, Registered Nurse 2 (RN 2) stated when a resident is admitted from the hospital to the nursing facility, the hospital discharge medication list should be clarified with attending physician to obtain orders to continue the orders or not. RN 2 stated, the GACH discharge paper works that came with Resident 1 when the resident was admitted on [DATE] should have been thoroughly reviewed by the admitting license nurse to ensure they can obtain the complete and/ or accurate order from Physical for Resident 1's Plavix. During an interview on 5/20/2025 at 1:43 PM, the Medical Records (MR) stated an admission audit would be done the next day for residents admitting or readmitting to the facility. MR also stated during the audit, the hospital discharge papers and orders from the admitting nurse would be reviewed to ensure they match. During an interview on 5/20/2025 at 2 PM, Physician 1 stated if the Nursing Facility notified Physician 1 of the Plavix being held until 4/30/2025 by MD 1, he would have ordered to hold Plavix until 4/30/2025. Physician 1 stated GACH discharge orders needed to be followed for continuity of care and to avoid worsening of the resident's condition. During a concurrent record review and interview on 5/20/25 at 2:20 PM with the DON of Resident 1's admitting medication orders and GACH discharge medication list, dated 4/21/2025, the DON stated during admission, the nurse admits a resident, then medical records department would do the audit of the resident's medical record to ensure the discharge orders from the hospital matches the physician orders. The DON also stated Resident 1's admitting orders to give the resident's Plavix with start date of 4/22/2025 did not match Resident 1's GACH discharge medication list/ orders to start the Plavix on 4/30/2025. The DON further stated it is important to follow the discharge orders from the hospital for accurate care of the resident and that nurses should have clarified the GACH discharge orders with the resident's physician upon admission. During an interview on 5/20/2025 at 4:21 PM, RN 1 stated Resident 1's admitting medication orders and Resident 1's GACH discharge medication list does not match but should have matched to ensure continuity of care and that the Plavix was given to Resident 1 on 4/30/2025 and not on 4/22/2025. RN 1 also stated she used the medication list that was faxed by the GACH nurses to the facility (no start dates) and not the GACH discharge medication list (with start dates) that was given to the Resident 1. RN 1 also stated, there was no documented evidence in Resident 1's medical records that the facility assessed, monitored and documented Resident 1 for specific signs and symptoms of bleeding/ hematoma / hemorrhage specifically for Resident 1's S/P lumbar decompression and fusion posterior, and Plavix use from 4/22/2025 to 4/25/2025. During an interview on 5/21/2025 at 12 PM, Physician 2 stated he would generally wait 2 weeks after surgery before ordering to give an anticoagulant to patients. Physician 2 also stated if the nurses start a medication when they should not have, then that is wrong. Physician 2 stated sometimes the healthcare provider give dangerous medications to the reisdent and it can cause adverse effect. During an interview on 5/21/2025 at 12:25 PM, Physician 3 (GACH's doctor) stated Resident 1 had a surgery prior to being admitted in the skilled nursing facility on 4/21/2025. Physician 3 stated Resident 1 received Plavix from the facility earlier than it should have been given. Physician 3 stated, this placed Resident 1 at risk for bleeding and/ or brain bleed. Physician 3 stated, Plavix increased the risk of bleeding. During an interview on 5/21/2025 at 2:57 PM, Pharmacist 1 stated there was no documentation indicating Resident 1 was post spinal surgery. Pharmacist 1 also stated if the facility informed the pharmacy that Resident 1 was status post spinal surgery, administering Clopidogrel Bisulfate medication would have been questioned. During an interview on 5/21/2025 at 4 PM, MR stated while auditing Resident 1's admission record, she reviewed the hospital faxed medication list (no start dates) and not the hospital discharge medication list (with start dates) that was given to Resident 1. MR also stated she should have reviewed the hospital discharge medication list when auditing the admission record but rather reviewed the fax medication list instead. MR stated the medication orders MR also stated, there was no documented evidence in Resident 1's medical records that the licensed nurses assessed, monitored and documented Resident 1 for specific signs and symptoms of bleeding/ hematoma / hemorrhage specifically for Resident 1's S/P lumbar decompression and fusion posterior, and Plavix use from 4/22/2025 to 4/25/2025. During a review of Resident 1's Nurse Notes, dated 4/27/2025 at 2:09 PM, the Nurses Notes indicated Family 1 came to notify the facility that Resident 1 passed away at the GACH on 4/27/2025. During a review of Resident 1's Death Certificate, printed on 5/21/2025, the Death Certificate indicated immediate cause for death is nontraumatic intracranial hemorrhage. During a review of the facility's Policy and Procedure (P&P) titled admission Assessment and Follow Up: Role of the Nurse, revised 9/2012, the P&P indicated reconcile the list of medications from the medication history, admitting orders, the previous MAR, and the discharge summary from the previous institution. During a review of the facility's P&P titled Medication and Treatment Orders, revised 7/2016, the P&P indicated orders for medications must include number of doses, start and stop date, and/ or specific duration of therapy. During a review of the facility's P&P titled Physician Orders, revised 7/2016, the P&P indicated all orders must be specific and complete with all necessary details to carry out the prescribed order without any questions. During a review of the facility's P&P titled Anticoagulation, revised November 2018, the P&P indicated as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated (treated or rendered unable to clot); for example, those who have recent surgery. The P&P also indicated the physician will prescribe anticoagulation therapy appropriately, consistent with recognized guidelines (piece of information that suggests how something should be done).