The Rehabilitation Center on Pico

In the surveyor’s words

From the most serious findings on record at The Rehabilitation Center on Pico, in the surveyor’s own words.

• Immediate jeopardy, widespreadF760Feb 27, 2025

  Based on observation, interview and record review, the facility failed to ensure 11 of 20 sampled residents (Resident 1, 8, 10, 11, 32, 37, 50, 54, 66, 95, and 99), were free of significant medication error. The facility failed to: -Ensure Resident 50 was administered Eliquis (apixaban, an anticoagulant, a blood thinner), Norvasc (amlodipine, a medication used to treat high blood pressure), and aspirin for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), in accordance with the physician's orders for eleven days during February 2025. […]

• Actual harm, isolatedF600Sep 6, 2024

  Based on interview and record review, the facility failed to protect the resident's right to be free from abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1), who had diagnoses of mood affective disorder (a condition that affects a persons emotions) and unspecified psychosis (a condition that makes people lose contact with reality, seeing and hearing things that other people cannot, and believing things that are not true). The facility failed to: -Ensure a complete and adequate comprehensive assessment on 5/29/2024 and 7/24/2024, including cognitive patterns, mood, behaviors, and active diagnoses. […]

• Actual harm, isolatedF689Mar 29, 2024

  Based on interview, and record review, the facility failed to assure that services being provided meet professional standards of practice for two of three sampled residents (Resident 1 and Resident 2). For Resident 1, the facility failed to: a. Evaluate and analyze hazards and risks for Resident 1 who is had multiple falls. b. Monitor for the effectiveness and modify interventions for a resident who is a non-compliant. As a result, on 3/13/2024, Resident 1 had a fall from his wheelchair when attempted to transfer himself to his bed and was found on the floor. Resident 1 was transferred to GACH 1 via 911 and sustained a right ankle fracture. For Resident 2, who had severely impaired vision, the facility failed to: c. Complete an accurate Fall Risk Assessment on 9/4/2024. d. […]

• Actual harm, isolatedF689Feb 23, 2024

  Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 3), who was a high risk for falls, had a history of multiple falls, and impairment to both lower extremities, received care and services to prevent accidents and falls by failing to: -Revise / update Resident 3's Risk for Falls care plan after the resident had a fall on 8/3/2023 and 9/17/2023. -Implement the Interdisciplinary Team (IDT, group of health care professionals with various areas of expertise who work together toward the goals of their clients) recommendations for Resident 3 to utilize a Geriatric Chair (Geri chair, a large, padded chair with a wheeled base that can recline. […]

• Actual harm, isolatedF689Jan 12, 2023

  Based on interview and record review the facility failed to follow its fall management program for one of two sampled residents (Resident 1) who was identified as high risk for fall by failing to: 1. Identify hazards and risks of Resident 1 unwitnessed falls on 11/28/2022, 11/29/2022, and 12/2/2022. 2. Ensure revision of the Fall Risk care plan for Resident 1 after the unwitnessed on 11/28/2022 and 11/29/2022. 3. Identify and develop new interventions related to the resident's specific risks and causes to try to prevent further falls after each unwitnessed fall on 11/28/2022 and 11/29/2022. These deficient practices resulted in Resident 1's transfer to a General Acute Care Hospital (GACH) via Emergency Medical Services (EMS) on 12/2/2022 for further evaluation and treatment due to fall. […]