Inspection·August 27, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, medical record review, and facility Policy and Procedure (P&P) review, the facility failed to ensure: Residents Affected - Some 1. A system was developed and implemented to accurately track the movement of controlled medications (medications with high potential for abuse or addiction) to prevent and identify loss or potential diversion (illegal distribution or use for purposes not intended by the prescriber) of controlled medications when the facility was unable to account for the missing controlled medications for ten residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10). This failure had resulted in controlled medication abuse or diversion. 2. Accurate accountability of controlled medications. During a random controlled medication audit for four of six sampled residents (Residents 9, 11, 12, and 13), the controlled medications were signed out of the Count Sheet (a controlled medication record, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Records (MAR) to indicate they were administered to the residents. This failure resulted in inaccurate accountability of controlled medications, which had the potential for misuse or diversion. Findings: On August 26, 2024, at 8:40 a.m., an unannounced visit was made to investigate a facility report of an unusual occurrence regarding missing controlled medications. 1. During an interview on August 26, 2024, at 9 a.m.,with the Director of Nursing (DON), the DON stated, on the morning of August 16, 2024, the DON received a phone call from Licensed Vocational Nurse (LVN) 1 about missing controlled medication count sheets and controlled medication cards for two residents (Residents 4 and 9). The DON, after being informed by LVN 1, the same day, started the investigation. The DON stated the investigation included inspection of all medication carts, nursing stations, medication disposal areas, medication disposal bins, trash cans, paper document shred bins, rechecked controlled medication count, reviewed recent MAR, and interviewed nursing staff. The DON stated the investigation identified a total 10 residents (Residents 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10) that were missing controlled medication count sheets and controlled medication cards. The DON stated all residents who were missing controlled medications received refills from the pharmacy and no residents missed doses of (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 4 Event ID: 055401 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 055401 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Meadowbrook Post Acute 461 E. Johnston Avenue Hemet, CA 92543 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)