Health inspection·October 17, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the necessary pharmacy services were provided to one of three sampled residents (Residents 1). * The facility failed to ensure the Geodon medication administered to Resident 1 was not from another resident's Geodon medication vial. In addition, the facility failed to ensure the discontinued Geodon medication was kept in the designated area to be disposed. These failures had the potential to cause unsafe administration and handling/storage of the residents' medications. Findings: Review of the facility's P&P titled Storage of Medications dated on 4/2008 showed medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized. The P&P further showed except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area. Review of the facility's P&P titled Medication Administration - General Guidelines dated 10/2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by the persons legally authorized to do so. Medication supplied for one resident are never administered to another resident. Medical record review for Resident 1 was initiated on 10/16/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/10/24, showed Resident 1 hadthe mental capacity to make medical decisions. Review of Resident 1's IDT Note dated 10/14/24 at 1506 hours, showed a follow-up IDT meeting was conducted. The note showed on 8/31/24 at 2030-2100 hours, the LVN noted Resident 1 was screaming loudly, attempting to go her roommate area, not listening to the staff, and refused to go back to bed. The LVN notified the NP and received an order to administer Geodon IM medication. The note further showed Resident 1 received the Geodon IM medication. On 10/17/24 at 1525 hours, an interview with the DON was conducted. The DON acknowledged Resident 1 was administered Geodon IM as a one-time dose ordered by the NP. The DON verified the Geodon (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 055206 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055206 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Plaza Healthcare Center 1209 Hemlock Way Santa Ana, CA 92707 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)