Health inspection·July 19, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interviews and record review, the facility failed to ensure accurate documentation in the medical records for three of three sampled residents (Resident 1, Resident 2, Resident 3) when the facility's Corporate Registered Nurse (RN 1) administered medications to the residents and signed the Medication Administration Record (MAR) with the initials of another nurse (Registered Nurse 2). This failure resulted in inaccurate information in Resident 1, Resident 2, and Resident 3 ' s medical records and prevented assessment of the administering nurse ' s medication administration performance in the event of medication error. Findings: A review of Resident 1 ' s MAR dated 4/25/22, indicated the initials of Registry Nurse 2 (RN 2) were in the area reserved for the nurse who administered the medications for four medications (Carbidopa-levodopa, Gabapentin, Ferrous Gluconate, Lisinopril) administered at 9 a.m. on 4/25/22. A review of Resident 2 ' s MAR dated 4/25/22, indicated the initials of Registry Nurse 2 (RN 2) were in the area reserved for the nurse who administered the medications for five medications (Fludrocortisone acetate, Carbazepine, Sensosides, Keppra, Tylenol/Acetaminophen) administered at 9 a.m. on 4/25/22. A review of the Resident 3 ' s MAR dated 4/25/22, indicated the initials of Registry Nurse 2 (RN 2) were in the area reserved for the nurse who administered the medications for two medications (Clopidogel Bisulfate, Riaroxaban) administered at 9 a.m. on 4/25/22. During an interview on 6/2/22, at 1:52 p.m., with RN 1, RN 1 stated she had administered the 9 a.m. medications for Resident 1, Resident 2, and Resident 3 on 4/25/22. RN 1 stated she had used RN 2's initials on the MAR to document the administration of the medications instead of her own initials. During an interview on 6/2/22, at 2:30 p.m., with RN 1, RN 1 stated RN 2 had been assigned to be responsible for medication administration for Resident 1, Resident 2 and Resident 3 on 4/25/22, but had been called in to work late as a replacement for another nurse. RN 1 stated she had been concerned RN 2 would not be able to administer the morning medications on time, so had administered Resident 1, Resident 2, and Resident 3's medications for RN 2. A review of the American Nurses ' Association (ANA) e-book titled, ANA ' s Principles of Documentation, Guidance for Registered Nurses, dated November 2010, indicated, Principle 5. Documentation Entries: Entries into organization documents or the health record (including but not limited to provider Page 1 of 2 055338 055338 07/19/2023 Sage Post Acute 1832 B Street Hayward, CA 94541

F 0842 Level of Harm - Minimal harm or potential for actual harm orders) must be accurate, valid, and complete; authenticated; that is, the information is truthful, the author is identified, and nothing has been added or inserted; dated and time-stamped by the persons who created the entry; legible/readable; and made using standardized terminology, including acronyms and symbols. Residents Affected - Some 055338 Page 2 of 2