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 (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 3 Event ID: 055237 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 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 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)