Health inspection·December 19, 2023

F 0710 Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to supervise medical care by a licensed physician according to the facility ' s policy and procedure (PP) titled, Physician Services, for one of four sampled residents (Resident 1) by failing to: Residents Affected - Some 1. Ensure Medical Doctor 1 (MD 1) provided care after attempting to be notified by RN 1 and RN 2 to resume Resident 1 ' s home medications in a timely manner for the following medications: a. Xarelto 20 (medication to treat and prevent blood clots (an important process that prevents excessive bleeding when a blood vessel is injured]) milligram (mg, unit of measurement) by mouth one time a day for atrial fibrillation (a type of irregular heartbeat). b. Rhopressa Ophthalmic Solution eyedrop (medication to treat loss of vision), instill one (1) drop in both eyes at bedtime for glaucoma (nerve connecting the eye to the brain is damaged). c. Prolensa eyedrops (medication to treat dry eyes, swelling, or pain in the eyes) 0.07 percent (%, one part of every hundred), instill one (1) drop both eyes in the morning for dry eyes, wait for three (3) to five (5) minutes for next eye drop. d. Besivance Ophthalmic Suspension 0.6 % eyedrop (medication to treat dry eyes), instill one (1) drop right eye twice a day for dry eye. e. Vyzulta Ophthalmic Solution eyedrop (medication to treat dry eyes), instill one (1) drop both eyes every night for dry eyes. 2. Ensure the facility ' s Medical Director (MDD) supervised the care for Resident 1 when MD 1 was not reachable by phone from RN 1 These deficient practices resulted in Resident 1 not receiving Resident 1 ' s home medication on time and had the potential to cause blood clots and/or worsening eye condition due to the lack of optimal therapeutic drug levels (dose range of a drug that provides safe and effective therapy) of each medication that was missed from 11/25/2023 to 11/29/2023 for Rhopressa (five [5] days), from 11/25/2023 to 11/30/2023 for Xarelto (six [6] days), 11/25/2023 to 12/7/2023 for Vyzulta eyedrop (13 days), and from 11/25/2023 to 12/8/2023 for Prolensa and Besivance eyedrops (14 days). Findings: During a review of Resident 1 ' s admission Record (AR), the AR indicated Resident 1 was admitted Page 1 of 3 055187 055187 12/19/2023 Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706

F 0710 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to the facility on [DATE], with diagnoses including legal blindness (even with glasses a person cannot see), paroxysmal atrial fibrillation, and a fractured right pubis (break of right bone in the pelvis). During a review of Resident 1 ' s Minimum Data Set (MDS- a standardized resident assessment and care screening tool), dated 11/25/2023, the MDS indicated Resident 1 had intact cognition (ability to think, remember, and reason). The MDS indicated Resident 1 required partial/moderate (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with eating, oral hygiene, and personal hygiene. The MDS indicated Resident 1 was dependent (helper does ALL the effort. Resident does none of the effort to completely the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, showering/bathing self, upper and lower body dressing, and putting on/taking footwear. During a review of Resident 1's History and Physical (H&P), dated 11/28/2023, the H&P indicated Resident 1 was diagnosed with glaucoma. During an interview with Resident 1 on 12/19/2023 at 12:35 PM, in Resident 1 ' s room, Resident 1 stated Family Member 1 (FM1) faxed Resident 1 ' s home medication list (HML) to the facility on [DATE]. Resident 1 stated, it took a while (unknown time frame by Resident 1) for the facility to get the orders for Resident 1 ' s missing medication from MD 1. During a concurrent interview and record review on 12/19/2023 at 4:02 PM, with the Registered Nurse 1 (RN1), Resident 1 ' s HML, Progress Notes, Order Summary Report (OSR), and Medication Administration Record (MAR, legal record of medication administration to residents in a facility) were reviewed. RN 1 stated Resident 1 ' s FM 1 faxed Resident 1 ' s HML to the facility on [DATE]. RN 1 stated the facility was in receipt of Resident 1 ' s HML list, including Resident 1 ' s home medication Xarelto, Rhopressa, Prolensa, Besivance, and Vyzulta. RN 1 stated Resident 1 ' s HML was faxed to MD 1 ' s office on 11/25/2023. RN 1 stated Resident 1 ' s progress note, dated 11/29/2023 indicated the facility was in receipt of Resident 1 ' s Xarelto and Rhopressa eyedrop medication on 11/29/2023. RN 1 stated Resident 1 ' s progress note, dated 12/4/2023 indicated RN 1 followed up with MD 1 ' s office regarding Resident 1 ' s other HML for reconciliation (the process of comparing a patient's medication orders to all the medications that the patient has been taking). RN 1 stated MD 1 ' s office personnel staff (unidentified) would get back to the facility with a response from MD 1. RN 1 stated Resident 1 ' s progress note, dated 12/5/2023, RN 1 contacted MD 1 ' s office to follow up on Resident 1 ' s Prolensa, Besivance, and Vyzulta medications. The progress note indicated MD 1 ' s office would get back to the facility with a response from MD 1. RN 1 stated Resident 1 ' s progress note, dated 12/7/2023 indicated RN 2 attempted to contact MD 1 ' s office for approval to order Resident 1 ' s remaining home medication eyedrops. RN 1 stated Resident 1 ' s progress note, dated 12/7/2023 indicated Resident 1 ' s eyedrop medications were received. RN 1 stated Resident 1 ' s OSR, dated 11/29/2023 indicated Resident 1 ' s Xarelto and Rhopressa eyedrop were ordered by MD 1. RN 1 stated Resident 1 ' s OSR, dated 12/7/2023 indicated Resident 1 ' s Prolensa, Besivance, and Vyzulta eyedrops were ordered by MD 1. RN 1 stated Resident 1 ' s MAR, dated for the month of November and December 2023 indicated Resident 1 received Rhopressa on 11/29/2023 and Xarelto on 11/30/2023. RN 1 stated Resident 1 ' s MAR indicated Resident 1 received Vyzulta eyedrop on 12/7/2023, and Resident 1 ' s Prolensa and Besivance eyedrops on 12/8/2023. RN 1 stated MD 1 was difficult to reach and would leave messages with MD 1 ' s office personnel staff (unidentified). RN 1 stated RN 1 did not know when MDD needed to be contacted when residents (in general) medical doctors (in general) did not respond to residents ' medication reconciliation timely. RN 1 stated RN 1 did not notify MDD when MD 1 was not reachable. RN 1 stated a delay in receipt of medication orders had the potentially to worsen Resident 1 ' 055187 Page 2 of 3 055187 12/19/2023 Garden View Post Acute Rehabilitation 14475 Garden View Lane Baldwin Park, CA 91706

F 0710 s medical condition, leading to complications, injury, and or even death. Level of Harm - Minimal harm or potential for actual harm During a review of the facility ' s undated Policy and Procedure (PP) titled, Physician Services, the PP indicated, It is the policy of this facility that each resident shall be under the care of a licensed physician. Physician services include [ .] a medical evaluation of the resident and review of orders for care and treatment. Residents Affected - Some During a review of the facility ' s policy and procedure titled, Significant Change in Condition, Response revised on 1/2022, indicated The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. 055187 Page 3 of 3