Health inspection·April 4, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure safe provision of pharmaceutical services for two of two sampled residents (Resident 10 and 11) by failing to: 1. Ensure Resident 10's physician ordered medication Cilostazol and Memantine HCI were not on the desk at Nurse Station (NS) 1 unsupervised. 2. Ensure Resident 11's physician ordered medication Metoprolol was not on the desk at NS 1 unsupervised. These deficient practices had the potential for diversion of medication and/or ingestion by other residents of the facility which could lead to harm. Findings: a. During a review of Resident 10 ' s admission Record (AR), the AR indicated, Resident 10 was admitted to the facility on [DATE] with diagnoses including peripheral vascular disease (PAD- a circulatory condition where blood vessels outside the heart and brain narrow, become blocked, or spasm), dementia (progressive loss of cognitive function, including memory, thinking, and reasoning, that significantly impairs a person's ability to perform daily activities), and Parkinsonism (a syndrome characterized by tremor, rigidity, and postural instability). During a review of Resident 10 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 02/28/2025, the MDS indicated, Resident 10 was severely impaired (never/rarely made decisions) in cognitive skills (the ability to make daily decisions). The MDS indicated Resident 10 was dependent on staff for toileting, oral hygiene, personal hygiene, putting on/taking off footwear, and lower body dressing. The MDS indicated, Resident 10 always needed substantial/maximal assistance (helper does more than half the effort) for eating. During a review Resident 10 ' s Order Summary Report (OSR, all active physician orders), indicated Resident 10 was prescribed Cilostazol (treats intermittent problems with blood flow in legs) 50 milligrams (mg- a unit of mass or weight equal to one thousandth of a gram) one tablet two times a day for PAD and Memantine HCI (treats dementia associated with Alzheimer ' s disease) 10 mg one tablet twice daily for dementia. b. During a review of Resident 11 ' s AR, the AR indicated, Resident 11 was admitted to the Page 1 of 2 055344 055344 04/04/2025 Claremont Heights Post Acute 590 S. Indian Hill Blvd. Claremont, CA 91711

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE], with diagnoses including type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), hypertension (high blood pressure), and anemia (a condition in which the blood doesn ' t have enough healthy red blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). During a review of Resident 11 ' s MDS, dated 2/20/2025, the MDS indicated, Resident 11 was dependent on staff for toileting, dressing, and bathing. During a review of Resident 11 ' s OSR, dated 4/18/2025, indicated Resident 11 was prescribed Metoprolol (treat high blood pressure, chest pain, and heart failure) 25 mg one tablet twice daily for hypertension. During a concurrent observation and interview on 4/4/2025 at 6:05 a.m. with LVN 2 at NS 1, three medication packets belonging to Resident 10 (Cilostazol and Memantine HCI) and Resident 11(Metoprolol) were observed. LVN 2 stated, I put them there on the desk because I am changing them out when I take them out the cart, I should have put them in the medication room and popped each pill out and put it in the waste (incinerator jar). LVN 2 stated the medications were not disposed of properly. LVN 2 stated other resident's of the facility could have come and taken the medication that was not prescribed to them nor supervised. During a concurrent observation and interview on 4/4/25 at 6:20 a.m. with RN 1 at NS 1, RN1 stated the medication packets did not belong on the desk. RN 1 stated LVN 2 did not follow the facility's policy and should have disposed of the medications properly. The facility policy was to remove the medication from the medication cart, document with another nurse in the medication destruction binder (name, date, medication name, prescription number, amount of medication destroyed, and the signatures of witnesses) and place the medication in the incineration container. RN 1 stated residents not prescibed the medication could have come, taken the medication, and become sick. During a review of the facility ' s updated policy and procedure (P&P) titled, Medication Destruction, dated 08/2019 indicated, discontinued medication and medications left in the facility after a resident's discharge are destroyed. The licensed nurse(s) and/or pharmacitst witnessing the destruction ensures that the fillowing information is entered on the (medication disposition form): date of destruction, resident's name, name and strength of medication, prescription number, amount of medication destroyed, and signatures of witnesses. 055344 Page 2 of 2