Health inspection·September 13, 2024

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 ensure one of three residents (Resident 1) received medications as ordered by the physician. This failure had the potential to compromise the resident's health and well-being. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including cellulitis (a type of skin infection) and other disorders of the skin and subcutaneous tissue (the deepest layer of skin). Review of Resident 1's Order Summary Report indicated she had physician orders, dated 8/3/24, for the following medications: 1. Cleocin-T External Lotion (antibiotic lotion used to treat infection) 1% (unit of dose measurement) apply to affected areas topically (to the skin) two times a day for infection; 2. Mupirocin External Ointment (medication used to treat infection) 2% apply to affected area topically three times a day for infected skin; 3. Diclofenac Sodium External Gel (medication used to treat pain) 1% apply to affected area topically four times a day for pain; and 4. Nyamyc External Powder (medication used to treat skin infections caused by fungus) 100,000 units per gram (unit of dose measurement) apply to abdominal fold/groin area topically four times a day for MASD (moisture-associated skin damage). Resident 1's medication administration record (MAR) and treatment administration record (TAR), dated 8/2024, were reviewed. On 8/3/24 and 8/4/24, there were multiple scheduled times for which the above medications were not documented as administered. Instead, the nurses who were supposed to administer the medications documented, 9. Further review of the MAR and TAR indicated a documentation of 9 meant, See Progress Notes. Review of Resident 1's Progress Notes, dated 8/3/24 and 8/4/24, indicated licensed nurse A (LN A) and LN B documented the above medications were on order. During an interview and concurrent record review with LN A on 9/11/24, at 4:11 p.m., LN A reviewed Resident 1's medical record and acknowledged the documentations of 9 and on order regarding the medications mentioned above. LN A stated that on order meant the pharmacy had not yet delivered the medications to the facility. LN A stated she looked for Resident 1's medications but could not find them. During an interview and concurrent record review with LN B on 9/13/24, at 11:09 a.m., LN B reviewed Page 1 of 3 055388 055388 09/13/2024 San Jose Healthcare & Wellness Center 75 N. 13th Street San Jose, CA 95112

F 0755 Level of Harm - Minimal harm or potential for actual harm Resident 1's medical record and acknowledged the documentations of 9 and on order regarding the medications mentioned above. LN B stated he looked in the medication cart, treatment cart, and medication room and could not find Resident 1's medications. LN B confirmed that on the days and times he documented 9 and on order in Resident 1's medical record, he did not administer the medications because he could not find them in the facility. Residents Affected - Few The facility's Consolidated Delivery Sheets (documentation of medications delivered from the pharmacy) were reviewed. The delivery sheets indicated the facility did, in fact, receive all of Resident 1's above-mentioned medications on 8/3/24 at 2:31 a.m. (before the first doses were due to be administered). The facility's policy titled Medication - Administration, revised 1/1/12, indicated medications and treatments will be administered as prescribed. 055388 Page 2 of 3 055388 09/13/2024 San Jose Healthcare & Wellness Center 75 N. 13th Street San Jose, CA 95112

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the medical record was complete and accurate for one of three sampled residents (Resident 1) when there was no documentation that the nurse notified Resident 1's physician of multiple medications that were not administered. This failure had the potential to compromise the facility's ability to track and communicate care relevant to Resident 1. Findings: Review of Resident 1's medical record indicated she was admitted on [DATE] and had diagnoses including cellulitis (a type of skin infection) and other disorders of the skin and subcutaneous tissue (the deepest layer of skin). Review of Resident 1's Order Summary Report indicated she had physician orders, dated 8/3/24, for the following medications: 1. Cleocin-T External Lotion (antibiotic lotion used to treat infection) 1% (unit of dose measurement) apply to affected areas topically (to the skin) two times a day for infection; 2. Mupirocin External Ointment (medication used to treat infection) 2% apply to affected area topically three times a day for infected skin; 3. Diclofenac Sodium External Gel (medication used to treat pain) 1% apply to affected area topically four times a day for pain; and 4. Nyamyc External Powder (medication used to treat skin infections caused by fungus) 100,000 units per gram (unit of dose measurement) apply to abdominal fold/groin area topically four times a day for MASD (moisture-associated skin damage). Resident 1's medication administration record (MAR) and treatment administration record (TAR), dated 8/2024, were reviewed. On 8/3/24 and 8/4/24, there were multiple scheduled times for which the above medications were not documented as administered. During an interview with licensed nurse B (LN B) on 9/13/24, at 11:09 a.m., LN B confirmed he did not administer the above medications to Resident 1 because he was not able to find the medications in the facility. Further review of Resident 1's medical record indicated there was no documentation that LN B notified Resident 1's physician of the medications that were not administered. During a follow-up interview and concurrent record review with LN B on 9/13/24, at 11:54 a.m., LN B reviewed Resident 1's medical record and confirmed there was no documentation that he notified Resident 1's physician of the medications that were not administered. LN B stated he did notify the physician, but he did not document. LN B confirmed he was supposed to document this and stated, If it is not documented, it didn't happen. The facility's policy titled Completion & Correction, revised 1/1/12, indicated the facility will work to complete medical records in a standardized manner to provide the highest quality and accuracy in documentation. The policy indicated, Entries will be recorded promptly as the events or observations occur. Entries will be complete, legible, descriptive and accurate. The policy further indicated to document each time a physician is notified by phone or in person regarding a resident's condition. 055388 Page 3 of 3