Health inspection·October 31, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy review, the facility failed to ensure an assessment was completed to determine if a resident could safely self-administer, prior to medications being left at the bedside for 1 (Resident #49) of 1 resident reviewed for self-administration. Residents Affected - Few Findings included: A review of a facility policy titled, Self Administration of Medication, revised in December 2019, revealed, Purpose: To determine the ability of alert residents to participate in self-administration of medications. To maintain the safety and accuracy of medication administration. Procedures: 1. If a resident desires to participate in self-administration, the interdisciplinary team [IDT] will assess and periodically re-evaluate the resident based on change in the resident's status. 2. The resident's cognitive, communication, visual, and physical ability to carry out this responsibility will be evaluated. A review of Resident #49's admission Record indicated the facility admitted the resident on 11/07/2021 with diagnoses that included bilateral age-related cataracts. A review of Resident #49's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/10/2023, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had functional limitations in range-of-motion one side in their upper extremity (shoulder, elbow, wrist, hand). A review of Resident #49's physician orders revealed orders dated 05/19/2022 that instructed staff to instill one drop of brimonidine tartrate solution 0.1%, twice a day into both eyes for glaucoma; and one drop of dorzolamide hydrochloride-timolol maleate solution, 22.3-6.8 milligrams per milliliter, twice a day into the right eye for glaucoma. An order dated 06/02/2022, instructed staff to instill one drop of latanoprost solution 0.005% into both eyes at bedtime for glaucoma. The physician's orders did not indicate the resident self-administered the eye drops. During an observation on 10/29/2023 at 11:07 AM in Resident #49's room, there were three prescription bottles on the resident's overbed table. Resident #49 stated the bottles contained eye drops and there were two eye drops that the resident self-administered. During an observation on 10/30/2023 at 1:39 PM, Resident #49 was in bed reading a book. The prescription bottles of eye drops were no longer on the overbed table. The resident stated someone had removed the eye drops from the resident's room against the resident's will about a week ago, and now the Page 1 of 3 055237 055237 10/31/2023 Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627

F 0554 resident had to ask for the eye drops to administer them. Level of Harm - Minimal harm or potential for actual harm During an interview on 10/30/2023 at 1:46 PM, Licensed Vocational Nurse (LVN) #1 stated if the resident had been assessed for self-administration, then there would have been a lockbox for storage of their medications. LVN #1 stated staff handed Resident #49 a bottle of eye drops and then gave the resident instructions for administering them. LVN #1 indicated the eye drops were not supposed to be left in the resident's room. LVN #1 admitted to leaving the eye drops in Resident #49's room the previous day (10/29/2023). LVN #1 stated Resident #49 had just been assessed to self-administer the eye drops but the medications would no longer be left in the resident's room. Residents Affected - Few During an interview on 10/31/2023 at 12:29 PM, LVN #2 stated that if a resident wanted to self-administer medications, the resident would be assessed to make sure they were capable of self-administration, a physician's order had to be obtained, the medication would be kept on the medication cart, and the self-administration would need to be addressed on the resident's care plan. During an interview on 10/31/2023 at 1:58 PM, the Director of Nursing (DON) stated that a resident would be assessed to determine if they were capable of self-administration, the interdisciplinary team would discuss it, and a physician's order for self-administration would be obtained, prior to a resident self-administering medication. The DON acknowledged that Resident #49 was not assessed for self-administration prior to the survey. The DON said the eye drops should not have been left in the resident's room. The DON stated her expectation was that no medications be left at the bedside unless they are in a locked container. The DON stated she expected a resident to be assessed before they were allowed to self-administer. During an interview on 10/31/2023 at 2:07 PM, the Administrator stated he expected an assessment to be completed before medications were left at a resident's bedside. 055237 Page 2 of 3 055237 10/31/2023 Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and facility policy review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) was accurate for 1 (Resident #1) of 4 residents reviewed for PASARRs. Residents Affected - Few Findings included: A review of facility policy titled, PASRR [PASARR], revised in July 2023, revealed, 1. A PASRR shall be completed on every resident upon admission. If the resident is coming from the general acute care hospital, the PASRR will be done by the hospital as applicable. 2. After the admission, IDT [interdisciplinary team] members will review the assessment for accuracy and the need for PASRR Level II referral. A review of Resident #1's admission Record, revealed the facility admitted Resident #1 on 09/05/2023, with diagnoses that included generalized anxiety disorder and autistic disorder. Per the admission Record, on 09/09/2023, the resident received a diagnosis of unspecified psychosis. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/11/2023, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 0, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #1's active diagnoses included anxiety disorder and psychotic disorder. Additionally, the MDS revealed Resident #1 received antipsychotic, antianxiety and antidepressant medications, three of seven days during the seven-day review period. A review of Resident #1's care plan with an initiation date of 09/09/2023, revealed Resident #1 received antianxiety medication due to a diagnosis of anxiety. Another care plan with an initiation date of 09/09/2023, indicated the resident received antipsychotic medication related to psychosis. A review of Resident #1's Preadmission Screening and Resident Review Level 1 Screening, dated 09/06/2023, indicated the results were negative as Resident #1 had no serious mental illness. In an interview on 10/31/2023 at 12:37 PM, Licensed Vocational Nurse (LVN) #3 stated she referenced the physician's orders and the history and physical from the hospital to make sure a PASARR was accurate. She said if it was not accurate, she resubmitted it. LVN #3 agreed Resident #1's admission PASARR dated 09/06/2023 was not correct, and she resubmitted a revised PASARR during the survey. In an interview on 10/31/2023 at 1:58 PM, the Director of Nursing stated a PASARR should include a resident's pertinent diagnoses and if an admitting PASARR was not accurate, LVN #3 would submit a new one. 055237 Page 3 of 3