Health inspection·September 14, 2023

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, and record review, the facility failed to obtain and administer medications as ordered by the physician, for one of two sampled residents (Resident 1), when Trulicity injection (medication to treat high blood sugar) was not available to be administered on the scheduled dose. This failure had the potential for Resident 1's blood sugar to not be controlled and could lead to decline in overall health condition. Findings: On August 2, 2023, at 9:44 a.m., an unannounced visit was conducted at the facility to investigate a facility reported incident. On August 2, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar). A review of the physician orders for July 2023, Resident 1 had a physician order, dated August 22, 2022, to administer Trulicity 0.75mg (milligram - unit of measurement)/0.5ml (milliliter - unit of measurement) inject subcutaneously (under all the layers of the skin), one time a day every Monday for diabetes. A review of the Medication Administration Record (MAR), for the month of July 2023, indicated Trulicity was marked not administered to Resident 1 on July 24, 2023, or on any other day of the week. A review of the Progress Notes, dated July 24, 2023, at 9:17 p.m., indicated Trulicity was not available to be administered. There was no documented evidence the medication Trulicity injectable was administered to Resident 1 on July 24, 2023, or any other day of the week. There was no documented evidence the licensed nurse followed up with the pharmacy or the physician was notified the medication was not administered to Resident 1. On August 2, 2023, at 1:13p.m., Director of Nursing (DON) was interviewed. She stated Trulicity was not available and had not been administered to Resident 1. She stated the pharmacy had difficulty with the supply of the medication. She stated if a medication was not available to be administered to the resident, the licensed nurse should have followed up with the pharmacy for the medication supply. She stated the physician should have been notified of the unavailability of the medication for (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 2 Event ID: 055361 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 055361 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vista Pacifica Convalescent Hospital 3662 Pacific Avenue Jurupa Valley, CA 92509 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)