Health inspection·October 2, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure pharmacy services were provided to meet the needs of the residents, when several psychotropic medications (used to treat mental illness) were not administered in accordance with the physician's orders, for one of three residents reviewed (Resident 2). This failure had the potential for Resident 2 to have adverse reactions and changes in behaviors related to not receiving the prescribed medications. Findings: On June 2, 2023, at 2:17 p.m., an unannounced visit was conducted at the facility to investigate an altercation involving Resident 2, who was hit in the head by her peer, but no injuries were incurred. On June 2, 2023, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included paranoid schizophrenia (a severe mental health condition where a person feels distrustful and suspicious of others) and schizoaffective disorder (persistent mental health condition characterized by delusions and hallucinations). On September 19, 2023, Resident 2's record was further reviewed. The Order Review Report, included the following physician's orders: - .clonazePAM (medication used to treat panic and anxiety, calms the brain and nerves) Oral (by mouth) Tablet 0.5 MG (milligram- unit of measurement) (Clonazepam) Give 1 (one) tablet by mouth at bedtime for PARANOID SCHIZOPHRENIA ., date ordered April 11, 2023; - .Paliperidone ER (extended release - medication used to treat schizophrenia and schizoaffective disorder) Oral Tablet Extended Release 24 Hour 3 MG (Paliperidone) Give 1 tablet by mouth in the morning for SCHIZOAFFECTIVE DISORDER .; date ordered April 11, 2023; and - .Haloperidol (medication used to treat mood disorders) Tablet 10 MG Give 1 tablet by mouth at bedtime for paranoia MB (manifested by) verbal aggression ., date ordered May 1, 2023. A review of Resident 2's Medication Administration Record, for the months of May and June 2023, indicated the following: - There were 21 days in May 2023 which indicated documentation to refer to progress notes 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 10/02/2023 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)