Health inspection·April 18, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 physician failed to accurately document in the physician ' s readmission order and facility failed to record on the Medication Administration Record (MAR) for one of three sampled residents (Resident 1) with gastrointestinal tube (GT- a tube surgically inserted used to deliver medications in fluid form and nutritional formula) to receive medications via GT and not by oral (mouth) when the resident was readmitted to the facility. Resident 1 was receiving medications via GT and the physician ordered the resident to be NPO (nothing per oral) and receive medication per oral. This deficient practice resulted in inaccurate documentation of Resident 1 to receive medications through the wrong route which could result in complication such as aspiration (inhalation of fluid or food into the lungs). Findings: During a review of Resident 1 ' s admission Record indicated the resident was admitted on [DATE] with diagnoses that included cerebral infarction (result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), type 2 diabetes mellitus (condition when the body cannot use insulin [hormone that turns food into energy] correctly and sugar builds up in the blood) and with gastrostomy. During a review of Resident 1 ' s History and Physical (H&P), dated 3/17/2025, indicated the resident could make needs known but could not make medical decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 3/24/2025, indicated the resident ' s cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 1 had a feeding tube for nutrition. During a review of Resident 1 ' s Order Summary (a physician ' s orders) indicated the following: a. On 3/17/2025, the physician ordered Resident 1 to be placed on NPO diet. b. On 3/17/2025, the physician ordered Resident 1 to receive Tylenol oral (by mouth) tablet 325 milligrams (mg, unit of measure) (Acetaminophen) 2 tablet by mouth every 6 hours as needed for mild pain (1-3) 650 mg total not to exceed (NTE) 3 grams (G, unit of measure) in 24 hours from all APAP (N-acetyl-para-aminophenol, non-opioid analgesic [group of pain relievers that do not contain opioids]) and antipyretic [reduces fever] agent utilized for treating pain and fever) sources. Page 1 of 3 055430 055430 04/18/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Non-pharmacological (using no medication) interventions for pain: 1=repositioning, 2=dim light /quiet environment, 3=relaxation, 4=distraction, 5=music, 6=massage. c. On 3/19/2025, a prescribed order for Tramadol hydrochloride (HCl) (medication used to treat severe pain) Oral Tablet 50 mg (Tramadol HCl) Give 1 tablet by mouth as needed for moderate- severe pain (4-10) may give twice a day (BID) as needed. non-pharmacological intervention for pain: 1=repositioning, 2=dim light / quiet environment, 3=relaxation, 4=distraction, 5=music, 6=massage. During a review of Resident 1 ' s Medication Administration Records dated 3/2025 to 4/2025 indicated the following: a. On 3/18/2025 timed at 10:30 AM, Resident 1 was given Tylenol 325 mg by mouth. b. On 3/19/2025 timed at 9:45 PM, Resident 1 was given Tramadol HCl 50 mg by mouth. c. On 3/20/2025 timed at 5:21 PM, Resident 1 was given Tramadol HCl 50 mg by mouth. d. On 3/21/2025 timed at 2:30 AM and 4:38 PM, Resident 1 was given Tramadol HCl 50 mg by mouth. Timed at 9:53 AM and 8:36 PM, Resident 1 was given Tylenol 325 mg by mouth. e. On 3/22/2025 timed at 7:42 AM, Resident 1 was given Tylenol 325 mg by mouth. Timed at 11:14 AM, Resident 1 was given Tramadol HCl 50 mg by mouth. f. On 3/23/2025 timed at 5:19 PM, Resident 1 was given Tylenol 325 mg by mouth. g. On 3/24/2025 timed at 1:15 AM and 2:17 PM, Resident 1 was given Tramadol HCl 50 mg by mouth. Timed at 9:37 AM and 6:37 PM, Resident 1 was given Tylenol 325 mg by mouth. h. On 3/25/2025 timed at 12:36 AM and 4:38 PM, Resident 1 was given Tylenol 325 mg by mouth. Timed at 8:45 AM and 7:47 PM, Resident 1 was given Tramadol HCl 50 mg by mouth. i. On 3/26/2025 timed at 11 AM and 5:30 PM, Resident 1 was given Tylenol 325 mg by mouth. Timed at 8:37 PM, Resident 1 was given Tramadol HCl 50 mg by mouth. j. On 3/27/2025 timed at 7:38 AM, Resident 1 was given Tylenol 325 mg by mouth. Timed at 10:46 AM, Resident 1 was given Tramadol HCl 50 mg by mouth. k. On 3/28/2025 timed at 4 AM, 10:08 AM and 5:36 PM, Resident 1 was given Tylenol 325 mg by mouth. Timed at 12:01 PM and 11:02 PM, Resident 1 was given Tramadol HCl 50 mg by mouth. l. On 3/29/2025 timed at 6:29 AM and11:02 PM, Resident 1 was given Tramadol HCl 50 mg by mouth. Timed at 6:24 PM, Resident 1 was given Tylenol 325 mg by mouth. m. On 3/30/2025 timed at 2:55 PM, Resident 1 was given Tylenol 325 mg by mouth. n. On 4/1/2025 timed at 8:01 PM, Resident 1 was given Tylenol 325 mg by mouth. o. On 4/3/2025 timed at 2:40 AM and 9:34 AM, Resident 1 was given Tylenol 325 mg by mouth. 055430 Page 2 of 3 055430 04/18/2025 Whittier Hills Health Care Ctr 10426 Bogardus Ave Whittier, CA 90603

F 0842 p. On 4/4/2025 timed at 1:23 AM, Resident 1 was given Tylenol 325 mg by mouth. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review of Resident 1 ' s physician orders and MAR on 4/18/2025 at 1:38 PM, with Registered Nurse Supervisor (RNS), RNS confirmed Resident 1 had a gastrointestinal tube (GT) and the physician order the resident to be NPO due to abdominal pain. RNS confirmed Tylenol 325 mg and Tramadol 50 mg were documented on the MAR during the month of 3/2025 and 4/2025 given by mouth. RNS stated if the resident was NPO nothing should be given by mouth to prevent aspiration. RNS stated the nurse should have clarified the medication when they saw the physician's order indicated to be given per oral and not GT. RNS stated the nurse should clarify with the Physician or Physician ' s Assistant (PA) and then refax order to pharmacy. RNS stated when prior to administering medication the nurse should check for right patient, right medication, right dosage, right route, right frequency and right documentation. Residents Affected - Some During a concurrent interview and record review of Resident 1 ' s physician orders and MAR on 4/18/2025 at 2:16 PM, Assistant Director of Nursing (ADON) confirmed with the medications Tylenol and Tramadol were given via mouth when Resident 1 had order to be NPO. ADON stated nurses need to check the order and need to make sure it was correct before signing the MAR. ADON stated nurse should check orders to know what the correct route for medication. A review of the facility ' s policy and procedure (P&P) titled Six Rights of Medication Administration dated 5/2019 indicated it was the policy of the facility to ensure that the six rights of medication administration were followed in order to ensure safety and accuracy of administration. The P&P indicated the six rights of medication administration are as follows in order to ensure safety and accuracy of administration: a. Right Resident - Resident is identified prior to medication administration b. Right Time - Medications are administered within prescribed time frames. c. Right Medication order- Medications are checked against the order before they are given. d. Right Dose - Medications are administered according to the dose prescribed e. Right Route - Medications are administered according to the route prescribed f. Right Documentation - Document administration or refusal of the medication after the administration or attempt 055430 Page 3 of 3