Health inspection·December 10, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure residents were treated with dignity and respect for one of seven residents (Resident 1) when two Certified Nurse Assistants (CNA 2, CNA 3) spoke loudly and disrespectfully to Resident 1 and accused her of taking her roommate's remote control and adjusting the television to face Resident 1.This failure placed Resident 1 at potential risk for emotional distress, depression, mental instability, and decline in overall health. During an interview on 11/25/25 at 9:38 a.m., Resident 1 reported two CNAs (CNA 2, CNA 3) accused her of turning her roommate's TV and taking the remote control. Resident 1 stated the CNAs spoke loudly and angrily, calling her a liar, which she found unprofessional and hurtful. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/25/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses: type 2 diabetes mellitus (DM2-- a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function ), other stimulant abuse, bipolar disorder (,a serious mental illness that causes unusual shifts in mood, ranging from extreme highs (mania or manic episodes) to lows (depression or depressive episode)), major depressive disorder (persistent feeling of sadness and loss of interest), post-traumatic stress disorder (extreme fear during or after witnessing or experiencing potentially traumatic events, such as war, accidents, natural disasters or sexual violence), chronic pain syndrome. During a review of Resident 1's Minimum Data Set assessment tool (MDS- resident assessment tool which indicated physical and cognitive abilities), dated 9/17/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During an interview on 11/25/25 at 10:46 a.m. with CNA 1, CNA 1 stated staff should not yell at residents to preserve their dignity. CNA 1 stated residents deserve to be treated with respect and yelling could make them feel belittled or depressed. During an interview on 11/25/25 at 11:54 a.m. with the Administrator (ADM), the ADM stated on 11/11/25 around 7:30 p.m., the Director of Staff Development (DSD) informed her two CNAs argued with Resident 1 and were immediately suspended. The ADM stated he interviewed alert residents who stated they heard arguing but could not identify who was involved. The ADM stated he interviewed Licensed Vocational Nurse (LVN 5), who witnessed the incident. The ADM stated LVN 5 reported CNA 2 and CNA 3 argued with Resident 1 and behaved inappropriately. The ADM stated CNA 2 and CNA 3 had final written warnings due to misconduct. The ADM stated CNA 2 and CNA 3 were terminated on 11/17/25.During an interview on 11/25/25, at 12:09 p.m. with the Registered Nurse (RN), the RN Page 1 of 15 055454 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated it was unacceptable for staff to yell at residents. The RN stated staff members must act appropriately and address the needs of the residents. The RN stated if a resident were to yell at staff, it would still be inappropriate for staff to respond by yelling at the resident. The RN stated the residents have a right to be treated with respect and dignity. During an interview on 11/25/25 at 1:45 p.m. with the Director of Nursing (DON), the DON stated staff must maintain residents' dignity and safety and should not raise their voices when speaking to residents. The DON stated raising one's voice when speaking to residents could cause emotional distress, lead residents to refuse food, or diminish their trust in staff. During a phone interview on 12/2/25, at 3:25 p.m. with CNA 2, CNA 2 stated Resident 1 took her roommate's television (TV) remote control and turned the TV away from her roommate's view to face herself. CNA 2 stated she and CNA 3 went to Resident 1's room, retrieved the remote, and redirected the television towards the roommate's view. CNA 2 stated Resident 1 told LVN 5 what happened and accused CNA 2 and CNA 3 of lying. CNA 2 stated they did not respond to the accusation. CNA 2 stated yelling at residents was never acceptable and all residents should be treated with dignity and respect. CNA 2 stated treating residents poorly could lead to depression or decline in residents' health. During a phone interview on 12/2/25 at 3:47 p.m. with CNA 3, CNA 3 stated she and CNA 2 entered Resident 1's room and found the roommate's TV positioned towards Resident 1. CNA 3 stated they repositioned the TV to face the roommate. CNA 3 stated while attending to the roommate's needs, Resident 1 yelled at her for moving the TV. CNA 3 stated she attempted to explain to Resident 1the need for privacy for the roommate, but Resident 1 continued arguing. CNA 3 stated she asked Resident 1 to quiet down because other residents were sleeping. CNA 3 stated she reported the incident to LVN 5, who asked Resident 1 to return to her room. CNA 3 stated staff should speak to residents respectfully and calmly to maintain their dignity and avoid causing emotional distress or depression. During a phone interview on 12/3/25 at 10:15 a.m. with LVN 5, LVN 5 stated staff should always speak respectfully to residents. LVN 5 stated using a disrespectful tone could place residents at risk for emotional distress, mental instability and decline in health. LVN 5 stated she witnessed CNA 2 and CNA 3 yelling at Resident 1 at the nursing station. LVN 5 stated Resident 1 reported I heard they were texting (ADM), but they were giving false information. LVN 5 stated CNA 2 and CNA 3 made statement such as, I'm not going to stop because at the end of the day, I could lose my job.the family didn't want you to use the TV.we are not liars, you are lying. LVN 5 stated the CNAs were inappropriate and disruptive. During a phone interview on December 3, 2025, at 3:13 p.m. with the ADM, the ADM stated she interviewed Resident 1, CNA 2, CNA 3, LVN 5, and the alert residents living in the same hallway as the incident. The ADM stated the alert residents heard Resident 1 yelling but could not identify other voices. The ADM stated Resident 1 argued back and forth with CNA 2 and CNA 3. During a concurrent interview and record review on 12/10/2 at 1:17 p.m. with the Infection Preventionist (IP), the facility's policy and procedure (P&P) titled, Promoting/Maintaining Resident Dignity, Dated 2025 was reviewed. The P&P indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality.Compliance Guidelines: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident's rights.10. Speak respectfully to residents. IP stated staff should communicate with residents professionally, avoiding yelling or scolding. The IP stated residents have the right to express themselves, and staff should not raise their voice or belittle them. IP stated staff should refrain from arguing with residents, respecting their right to disagree, as this can affect their dignity. IP stated the staff are 055454 Page 2 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0550 Level of Harm - Minimal harm or potential for actual harm visitors in the residents' home, it is crucial to maintain their dignity and ensure they feel safe. IP stated the failure of staff to treat residents with respect may lead to emotional distress and potentially trigger depression. During a review of the facility's P&P titled, Resident Rights, dated 12/17/24, the policy indicated the resident has a right to be treated with respect and dignity. Residents Affected - Few 055454 Page 3 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to protect residents' rights and ensure they were free from misappropriation of property, medications were administered as prescribed, and controlled drugs were properly accounted for and discarded according to facility's policy and procedure for two of three sampled residents (Resident 5 and Resident 6) when License Vocational Nurse (LVN) 5 diverted controlled medications (drugs regulated by law for potential abuse, addiction, or dependence) prescribed for Resident 5 and Resident 6 for personal use and failed to properly document, discard discontinued medications according to facility's policies and procedures. These failures resulted in Resident 5 and Resident 6 not receiving their prescribed medications as ordered which placed them at risk for inadequate pain management and anxiety. During an interview on 11/25/25 at 12:09 p.m. with Registered Nurse (RN), the RN stated controlled substances were stored in the controlled substance drawer of the medication cart. The RN stated the facility had two medication carts; one located at each nursing station. Each medication cart had one controlled substance key which was maintained by the assigned Licensed Nurse (LN). The RN stated during shift change, two LNs would audit the controlled substances medications by reviewing the Controlled Substance Record (log used to document the actual pill count of controlled substance) and conduct a physical count of the total number of pills. The RN stated after verifying the record and count were accurate, both LNs signed the controlled substance records. The RN stated when a resident was discharged from the facility, the LN placed unused controlled substance medications in the discontinued section of the controlled substance drawer. The RN stated the LN was responsible for handing off discontinued controlled substances to the Director of Nursing (DON) when available. The RN stated upon transfer of discontinued controlled substances, the DON and the LN reviewed the discontinued controlled substance medication record, verified the total number of discontinued pills and both signed the controlled substance record after confirming the count was accurate. The RN stated if discrepancies were identified between the controlled substance record and the actual pill count, the LN would review the controlled substance record line items to identify the discrepancy. The RN stated if the discrepancy could not be resolved, the LN notifies the DON, Medical Director (MD), and the Administrator (ADM) for further investigation. During an interview on 11/25/25 at 12:40 p.m. with LVN 1, LVN 1 stated the LNs were responsible for managing and documenting controlled substances from the pharmacy through administration and discontinuation by physician order. LVN 1 stated controlled substances were stored in a secure medication cart, which included a separate locked drawer designated for controlled substances. LVN 1 stated only the nurse assigned to the nursing station-maintained possession of the key to the controlled substance drawer. LVN 1 stated when a controlled substance was administered, the LN signed the Controlled Drug Record, removed the bubble pack from the locked drawer, removed the prescribed dose, administered the medication to the resident, and documents the administration on the Medication Administration Record (MAR). LVN 1 stated the LN would verify the pill count and document on the Controlled Drug Record match the remaining quantity in the bubble packs. LVN 1 stated upon resident's discharged , all controlled drug substances should be delivered to the DON. LVN 1 stated licensed nurse give the controlled substance record and discontinued bubble packs to the DON for review and verification. LVN 1 stated after the pill count was verified, both the DON and the LN signed the controlled substance record, and the DON secured the discontinued controlled substance for destruction. LVN 1 stated if the DON was not available to receive discontinued controlled substances, the controlled substances were stored in the discontinued section of the controlled substance drawer inside the medication cart, and two LNs verified the Residents Affected - Few 055454 Page 4 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few controlled substance count at each change of shift until the DON was available for transfer. During a concurrent interview and record review on 11/25/25 at 1:45 p.m. with the DON, the facility's document titled Shift Change Controlled Substance Inventory Log, dated 11/14/25 was reviewed. The Shift Change Controlled Substance Inventory Log indicated Resident 5's oxycodone 5 mg quantity was zero. The DON stated Resident 5 was discharged home on [DATE]. The DON stated Resident 5's two bubble packs of Oxycodone (medication used to relieve pain) 5 mg (milligram- unit of measurement) remained in the controlled substance drawer after discharge. The DON stated on 11/14/25, LVN 5 documented on the Shift Change Controlled Substance Inventory Log (log used to document counts of controlled substance bubble packs) a count of zero for Resident 5's Oxycodone 5 mg, which indicated the bubble packs were emptied. The DON stated on 11/17/25, LVN 3 discovered Resident 5's two bubble packs of Oxycodone 5 mg were missing from the controlled substance drawer during shift change controlled substance count with LVN 4. The DON stated LVN 3 notified both her and the ADM of the suspected drug diversion on 11/17/25. The DON stated after interviewing LVN 5, she became aware LVN 5 had removed the corresponding sheet from the Controlled Substance Record Log and removed the two bubble packs of oxycodone 5 mg from the controlled substance drawer, resulting in the medication being untraceable. The DON stated LVN 5 admitted to taking Resident 5's two bubble packs of oxycodone 5 mg, each containing 30 pills. The DON stated she notified law enforcement and the facility pharmacy. The DON stated Resident 5 was discharged on 11/8/25 and the two bubble packs of oxycodone should have been given to her by the LN but was not done. The DON stated the facility's policy and procedure for Controlled Substance Administration & Accountability was not followed. During a record review on 11/25/25 at 2:59 p.m. with the DON, Resident 5's admission Record (AR-a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes) and Medication Administration Record (MAR) were reviewed. The AR, dated 11/25/25 indicated Resident 5 was admitted on [DATE] and discharged on 11/8/25 and had a history of muscle weakness, difficulty walking, alcoholic liver with ascites (liver damage cause by alcohol, with fluid buildup in your abdomen causing swelling), liver failure, encephalopathy (the liver is not working well enough such as filtering toxins, causing a condition affecting the brain that can cause confusion), Type 2 Diabetes Mellitus (a condition where your body does properly use insulin, leading to high blood sugar), alcoholic dependence(a condition in which a person has difficulty stopping alcohol use) and had spinal surgery on 9/7/25. The MAR indicated Resident 5 had a physician order for Oxycodone 5 mg as follows: give one tablet by mouth every four hours as needed for moderate pain and give two tablets by mouth every four hours as needed for severe pain. During a phone interview on 12/2/25 at 2:15 p.m. with LVN 3, LVN 3 stated she discharged Resident 5 on 11/8/25. LVN 3 stated Resident 5 had three bubble packs of oxycodone 5 mg on the day of discharge, one partially used bubble pack containing 25 pills and two unopened bubble packs containing 30 pills each. LVN 3 stated the physician ordered the 25 pills to be sent home with Resident 5 and discontinued the two unopened bubble packs. LVN 3 stated the two discontinued bubble packs were stored in the controlled substance drawer of the medication cart but in a separate compartment designated for discontinued medications, to be included in the shift change controlled substance audit. LVN 3 stated on 11/14/25, during the morning shift, she completed the shift change controlled substance count with LVN 5. LVN 3 stated at that time, the two discontinued oxycodone bubble packs were present in the separate compartment in the controlled substance drawer, and verified the controlled substances were accounted for. LVN 3 stated on 11/17/25, during her morning shift, she completed the shift- change control substance count with LVN 6, no discrepancies were identified, as the discontinued oxycodone bubble packs were in the separate compartment and were not immediately recognized as 055454 Page 5 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few missing. LVN 3 stated later during her shift, she noticed that the two discontinued bubble packs were missing. LVN 3 stated during the end-of-shift controlled substance count with LVN 4, the incoming nurse, The absence of the two bubble packs was confirmed, and LVN 3 and LVN 4 notified the DON and ADM of the missing medications and potential drug diversion. LVN 3 stated when a resident is discharged , the LN was supposed to notify the DON, and the LN and the DON are responsible for removing the controlled medication from the controlled substance drawer for proper destruction. During a phone interview on 12/3/25 at 10:15 a.m. with LVN 5, LVN 5 stated when controlled substances were discontinued, the LN would leave it in the controlled substance drawer until the DON was notified and could remove the medication for proper destruction. LVN 5 stated the LNs were responsible for notifying the DON when discontinued controlled substances need to be removed. LVN 5 stated she was aware of Resident 5's two bubble packs of oxycodone in the controlled substance drawer. LVN 5 stated she documented zero count in the Shift Change Controlled Substance Inventory Log, removed the corresponding sheet from the Controlled Substance Record Log and removed the two bubble packs of oxycodone 5 mg from the controlled substance drawer, rendering the medication untraceable. During a phone interview on 12/3/25 at 1:44 p.m. with the Pharmacy Nurse Consultant (PNC), the PNC stated discontinued controlled substances should have been destroyed according to the facility's narcotic destruction protocol. The PNC stated the facility should maintain a section for discontinued medications and the LNs were supposed to give discontinued controlled substances to the DON for disposal after a resident's discharge. During a phone interview on 12/3/25 at 2:22 p.m. with the Pharmacy Consultant (PHARM), the PHARM stated discontinued controlled substances should have been handed off to the DON as soon as possible. The PHARM stated if the DON was not available, the LN should continue to count the controlled substance during shift change until they could be handed off to the DON. The PHARM stated the facility was required to monitor the number of controlled medications, and each LN was required to verify every narcotic on the log matched the actual number of medications locked in the controlled substance drawer. During a review of Resident 6's AR, dated 11/25/25, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses: fracture (a partial or complete break in a bone) of unspecified bone in left wrist, hyperlipidemia (high cholesterol), chronic pain syndrome, osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). During a review of Resident 6's Minimum Data Set assessment tool (MDSresident assessment tool which indicated physical and cognitive abilities), dated 10/10/25, the MDS indicated a Brief Interview for Metal Status (BIMS- an assessment of cognitive function (a mental process such as memory, language, or problem-solving that helps someone to think and process information) score of 12 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 6 had moderate cognitive impairment. During a concurrent interview and record review on 12/10/25 at 12:38 p.m. with the Infection Preventionist (IP), Resident 6's MAR dated 11/2025 and the Controlled Drug Record dated 10/23/25 were reviewed. The MAR indicated Hydrocodone-APAP [Acetaminophen] 10-325 (medication used to relieved pain): Give 1 tablet by mouth every four hours as needed for pain. The Controlled Drug Record indicated the Hydrocodone-APAP 10-325 had been signed out multiple times by LVN 5 for Resident 6 on 11/15/25 at 2 p.m., 11/15/25 at 6:19 p.m., 11/15/25 at 6:19 p.m., 11/15/25 at 10:11 p.m., 11/15/25 at 10:11 p.m., 11/16/25 at 1:30 p.m., and 11/16/25 at 6 p.m. The IP stated none of these administrations were Documented the MAR. The IP stated after the prior drug diversion was identified, the facility became aware of the out of sequence entries on the Controlled Drug Record. The IP stated the drug diversion concerns for Residents 6 was reported to the DON. During a phone interview on 12/16/25 at 1:15 p.m. with the PHARM, the PHARM stated it was important for the facility 055454 Page 6 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to ensure accurate controlled substance audits to prevent possible drug diversion. The PHARM stated drug diversion could place a resident at risk of not receiving their prescribed pain medication, which could result in uncontrolled pain, decreased quality of life, delayed healing, or a prolonged length of stay. During a concurrent phone interview and record review on 12/10/25 at 11:15 a.m. with the DON, the Controlled Substance Administration & Accountability P&P dated 12/17/24 were reviewed. The P&P indicated, 1.j. The charge nurse or other designee conducts a daily visual audit of the required documentation of controlled substances. The DON stated she audits the controlled substances daily Monday through Friday since the drug diversion incident on 11/17/25. The DON stated she does not perform controlled substance audits on Saturday and Sunday. The DON stated she would resume controlled substance audits on Monday and would review Saturday and Sunday at that time. During a professional reference review retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC3538481/ titled, Diversion of Drugs Within Health Care Facilities, a Multiple-Victim Crime: Patterns of Diversion, Scope, Consequences, Detection, and Prevention, dated 7/2012, the professional reference review indicated, .healthcare workers who are diverting drugs from the health care facility workplace pose a risk to their patients, their employers, their co-workers, and themselves. It is essential that all health care institutions have a robust system in place to identify and investigate suspected diversion as rapidly and efficiently as possible and that they implement policies and procedures that enable a standardized and effective response to confirmed diversion. Drug diversion by healthcare workers violates the core value that the needs of the patient come first. Clearly, if we are to optimize our approach to inpatient drug diversion and its consequences, we must look at such diversion not as a victimless act but as a multiple-victim crime . 055454 Page 7 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

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 observations, interviews and record review, the facility failed to maintain accurate controlled substance records, documentation and reconciliation in accordance with facility's policies and procedures for two of three sampled residents (Resident 5, 6) when the license nurses (LNs) failed to accurately document and account Resident 5 and Resident 6 controlled substance on the Controlled Drug Records and Medication Administration Record to accurately reflect the controlled substance disposition or resident administration.These failures resulted in the facility's delayed detection of controlled substances diversion for Residents 5 and 6, and placed residents at potential risk for medication errors, untreated pain, and overdose, compromising residents' safety and quality of care. During an interview on 11/25/25 at 12:09 p.m. with the Registered Nurse (RN), The RN stated when controlled substances were delivered, the licensed nurse (LN) checked the medications against the pharmacy manifest to ensure the resident name, medication name, dose, and instructions for use matched the physician's order. The RN stated after verifying, the LN and delivery person signed the manifest, which was filed at the nurse's station. The RN stated LNs recorded the received controlled substances on the Shift Change Control Substance Inventory Log. The RN stated each shift change, two LNs counted the pills in the narcotic drawer and compared them to the records. The RN stated if there was a discrepancy, the LN's reviewed documentation to identify and correct errors, and if it could not be resolved, the LNs notified the Director of Nursing (DON) and the Administrator (ADM). The RN's stated controlled substances required close monitoring because too much medication could cause drowsiness or overdose, placing residents at risk.During an interview on 11/25/25 at 1:45 p.m. with the DON, the DON stated when controlled substances were delivered to the facility, the pharmacy would deliver it directly to the LN. The DON stated the LN would verify with the delivery staff what was received, ensure the bubble packs were intact, and nothing was missing. The DON stated once the controlled substances were verified against the manifest, physician order and the bubble pack label, the LN and delivery staff would sign the manifest. The DON stated the LN would place the controlled substances in the double locked drawer of the medication cart. The DON stated the Controlled Drug Record was stored in a binder and the Shift Change Controlled Substance Inventory Log would be updated with the addition of the pharmacy delivery. The DON stated when the LN prepared to administer controlled substances, the LN should verify the count on the Controlled Drug Record and the bubble pack contents matched. The DON stated the LN should document the date, time and dose of the medication given on the Controlled Drug Record in the binder and in the MAR. The DON stated during shift change, the LN would verify the Shift Change Controlled Substance Inventory Log's recorded total sheets (bubble packs) at the end of the shift would match the number of bubble packs in the controlled substance drawer. The DON stated that LNs would compare the Controlled Drug Record's pill count with the number of pills in the bubble packs in the controlled substance drawer.During a review of Resident 5's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/25/25, the AR indicated Resident 5 admitted on [DATE], discharged [DATE] and had a history of muscle weakness, difficulty walking, alcoholic liver with ascites (a buildup of fluid in your abdomen causing a swollen belly), liver failure, encephalopathy (a disturbance of brain function that causes confusion, memory loss and coma in severe cases), Type 2 Diabetes Mellitus (a condition where your body does not use a hormone that helps move sugar from your blood into your cells for energy properly), alcoholic dependence and had spinal surgery on 9/7/25.During a review of Resident 5's Order Summary (OS) dated 9/23/25, the OS indicated oxycodone 055454 Page 8 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hydrocholoride (HCl) (drugs used to treat pain) Oral Tablet 5 mg Give 2 tablet by mouth every 4 hours as needed for severe pain.oxycodone HCl Oral Tablet 5 mg Give 1 tablet by mouth every 4 hours as needed for moderate pain.During a review of Resident 5's Controlled Drug Records dated 10/25/25, undated and 11/8/25, and the MAR dated [DATE], the Controlled Drug Record indicated Oxycodone HCL 5 mg Tablet Give 1 Tablet by mouth every 4 hours as needed for moderate pain, Give 2 tablets for severe pain. The MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain .Oxycodone 2 tablets by mouth every 4 hours as needed for severe pain. The Controlled Drug Record indicated oxycodone HCL was removed from the controlled drug drawer on 11/3/25 at 9 p.m., 11/4/25 at 1:34 p.m., 4:43 p.m., 9:44 p.m., and 11/5/25 at 6 a.m., and 7:37 p.m., 11/6/25 at 4:10 a.m., 7:55 a.m., 3:27 p.m., and 7:55 p.m., and 11/7/25 12:45 a.m. These medications removals were not documented on the MAR, and no corresponding record indicating refusal, wastage, or return.During a review of Resident 5's Controlled Drug Records dated 10/25/25, undated and 11/8/25, and the MAR dated [DATE], the Controlled Drug Record indicated Oxycodone HCL 5 mg Tablet Give 1 Tablet by mouth every 4 hours as needed for moderate pain, Give 2 tablets for severe pain. The MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain .Oxycodone 2 tablets by mouth every 4 hours as needed for severe pain. The Controlled Drug Record indicated oxycodone HCL was removed from the controlled drug drawer on 11/3/25 at 9 p.m., 11/4/25 at 1:34 p.m., 4:43 p.m., 9:44 p.m., and 11/5/25 at 6 a.m., and 7:37 p.m., 11/6/25 at 4:10 a.m., 7:55 a.m., 3:27 p.m., and 7:55 p.m., and 11/7/25 12:45 a.m. These medications removals were not documented on the MAR, and no corresponding record indicating refusal, wastage, or return.During a review of Resident 6's AR, dated 11/25/25, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses: fracture (a partial or complete break in a bone) of unspecified bone in left wrist, hyperlipidemia (high cholesterol), chronic pain syndrome, osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), age related osteoporosis (bones get weak and brittle, like a sponge with big holes, making them easy to break), fracture of T9-T10 vertebra (a broken bone in your mid-upper back), multiple broke right ribs, fractured coccyx (broken tailbone), and lower end of left radius fracture (broken wrist). During a concurrent interview and record review on 12/3/25 at 1:44 p.m. with the Pharmacy Nurse Consultant (PNC), the facility pharmacy 2nd Quarter Nurse Consulting Services Audit dated 5/20/25 were reviewed. The Medication Administration Observation Report indicated the controlled drug log was not signed in a timely manner. The PNC stated her role was to observe and audit medication administration process, perform medication cart, medication storage and treatment cart audits, and provide in-services to the facility staff when requested. The PNC stated she would report the audit findings to the DON during the exit interview.During an interview on 12/3/25 at 2:22 p.m. with the Pharmacy Consultant (PHARM), the PHARM stated his duties included teaching staff to handle controlled substances, ensuring correct counts in each cart, and making sure staff do not leave their shift if there was a discrepancy. The PHARM stated the facility had an end-to-end system in place, upon receipt of a delivery, the LN signed the receipt, documented administration, and handed discontinued controlled substances to the DON until they were destroyed in the presence of the pharmacist. The PHARM stated each nurse must verify every single controlled substance on the log matches what was locked in the controlled substance drawer. During a concurrent interview and record review on 12/10/25 at 11:12 a.m. with the DON, the facility's policy and procedure (P&P) titled, Controlled Substance Administration & Accountability dated 12/17/24 was reviewed. The P&P indicated .1. f. All controlled substances (Schedule II, III, IV, 055454 Page 9 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few V) are accounted for in one of the following ways.ii. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided.1. g. In all cases, the dose noted on the usage form.must match the dose recorded on the Medication Administration Record (MAR), Controlled Drug Record, or other facility specified form and placed in the patient's medical record. 1.h. The Controlled Drug Record .serves the dual purpose of recording both narcotic disposition and patient administration. 1.j. The Controlled Drug Record is a permanent medical record document and in conjunction with the MAR is the source of documenting any patient-specific narcotic dispensed from the pharmacy.10. Discrepancy Resolution: a. Any discrepancy in the count of controlled substances or disposition of the narcotic keys is resolved by the end of the shift during which it was discovered.c. Resolution can be achieved by review of dispensing and administration records and consulting with all staff with access. D. additional reports may be available from the pharmacy. E. any discrepancies which cannot be resolved must be reported immediately as follows: I. Notify the DON, charge nurse, or designee and the pharmacy; ii. Complete an incident report detailing the discrepancy, steps taken to resolve it, and the names of all licensed staff working when the discrepancy was noted; iii. The don, charge nurse, or designee must also report any loss of controlled substances where theft is suspected to the appropriate authorities such as local law enforcement, Drug Enforcement Agency, State Board of Nursing, State Board of Pharmacy and possibly the State Licensure Board for Nursing Home Administrators. F. Staff may not leave the area until discrepancies are resolved or reported as unresolved discrepancies. The DON stated that all medication administration must be recorded on the MAR. The DON stated controlled substance administration should match the MAR. The DON stated it was important to document in the MAR, so staff know what medication was administered or refused. The DON stated failing to document medication administration on the MAR could lead to a resident receiving an extra dose. The DON stated that unnecessary medication could worsen a resident's chronic conditions or cause an overdose, potentially leading to death.During a concurrent interview and record review on 12/12/25 at 2:26 p.m., with the DON, Resident 6's Controlled Drug Record dated 10/23/25 and the MAR dated [DATE], the Controlled Drug Record indicated Hydrocodone-APAP 10-325 Give 1 Tablet by mouth every 4 hours as needed for pain, the MAR indicated Hydrocodone-Acetaminophen Oral Tablet 10-325 mg Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain 4-10 start date 9/22/25 11:15 and discontinue (DC) date 11/21/25 16:49, The Controlled Drug Record indicated hydrocodone acetaminophen was removed from the controlled drug drawer on the following times: 11/15/25 at 21:40, 11/16/25 at 13:20,11/16/25 at 18:00, 11/15/25 at 14:00, 11/15/25 at 18:19, and 11/15/25 at 22:11. These medications removals were not documented on the MAR, and no corresponding record indicating refusal, wastage, or return. The Shift Change Controlled Drug Inventory Log Revealed multiple and accurate count computations. On 11/7/25 the controlled substance sheets (medication bubble packs) count began at 67; two sheets were added, and four sheets were subtracted. The correct ending count should have been 65; however, 66 was documented. On 11/9/25, the count began at 65; one sheet was added and two were subtracted. The correct ending count should have been 64; however, 65 was documented. On 11/10/25, the count began at 65 with no additions or subtractions, yet the ending count was documented as 64. On 11/14/25, the count began at 63; three sheets and three sheets were subtracted. The correct ending count should have remained 63; however, 57 was documented. On 11/16/25, the count began at 51; one sheet was added and three were subtracted. The correct ending count should have been 49; however, 51 was documented. The DON stated the controlled drug inventory calculation were inaccurate. The DON stated it was her responsibility to conduct controlled drug audits and she did not perform 055454 Page 10 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the audits as required. During an interview on 12/16/25 at 1:15 p.m. with the PHARM, the PHARM stated the Shift Change Controlled Substance Inventory Log and the Controlled Drug Record should not contain calculation inaccuracies. The PHARM stated shift change controlled substance audits were intended to identify potential diversion by staff. The PHARM stated if controlled substances were diverted, residents would be at risk for uncontrolled pain, which could negatively impact their quality of life and prolong the residents' stay. 055454 Page 11 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure residents were free from unnecessary medications administration for three of three sampled residents (Resident 1, 5, and 6) when license nurses (LN) assessed Resident 1, Resident 5, and Resident 6's pain levels as mild to moderate and administered pain medications prescribed for severe pain, not in accordance with the physician's order. These failures had the potential to place Resident 1, Resident 5, and Resident 6 at risk for over-medication, respiratory distress, impaired cognition, falls, and inadequate pain control. During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 11/25/25, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which includes type 2 diabetes mellitus (DM2-- a condition where the body has trouble controlling blood sugar levels, causing blood sugar to become high) and chronic pain syndrome. During a review of Resident 1's Medication Administration Record (MAR), the MAR indicated physician order for Hydrocodone-Acetaminophen [medication used to treat pain] 5-325 mg [milligrams- unit of measurements] give 1 tablet by mouth every 8 hours as needed for moderate to severe pain and Tramadol [medication use to treat pain] HCL [hydrochloride] 50 mg give one tablet by mouth every 6 hours as needed for moderate to severe pain. The MAR indicated Resident 1 received Hydrocodone Acetaminophen 5/325 mg on 11/4/25 at 12:06 a.m. for a reported pain level 3 out of 10. Tramadol 50mg was administered on 11/4/25 at 9:38 p.m., 11/6/25 at 3:11 a.m., 11/7/25 at 8:30 a.m., 11/8/25 at 9:03 a.m., and 11/28/25 at 11;36 a.m., for a reported pain level of 3 out of 10. During a review of Resident 5's AR, dated 11/25/25, the AR indicated Resident 5 was admitted on [DATE], discharged [DATE]. Resident 5 had a history of muscle weakness, difficulty walking, alcoholic liver with ascites (a buildup of fluid in your abdomen causing a swollen belly), liver failure, encephalopathy (a disturbance of brain function that causes confusion, memory loss and coma in severe cases), and had spinal surgery on 9/7/25. During a review of Resident 5's Order Summary (OS) dated 9/23/25, the OS indicated oxycodone [medication used to treat pain] HCl Oral Tablet 5 mg Give 2 tablet by mouth every 4 hours as needed for severe pain.oxycodone HCl Oral Tablet 5 mg Give 1 tablet by mouth every 4 hours as needed for moderate pain. During a review of Resident 5's MAR dated [DATE], the MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain. The MAR indicated oxycodone 2 tablets by mouth every 4 hours as needed for severe pain and was administered on 11/2/15 at 5:15 p.m., 11/3/25 at 1:56 a.m., 11/3/25 at 7:52 a.m., 11/3/25 at 12:44 p.m., 11/4/25 at 3 a.m., 11/4/25 at 8:04 a.m., 11/5/25 at 1:50 a.m., 11/6/25 at 12 a.m., and 11/7/25 at 4:34 a.m. for a reported pain level ranging from 3 out of 10 and 4 out of 10, indicating the pain oxycodone was given for pain below the physician ordered severity level. During a review of Resident 6's AR, dated 11/25/25, the AR indicated Resident 6 was admitted to the facility on [DATE] with diagnoses which included fracture (a partial or complete break in a bone) of unspecified bone in left wrist, , chronic pain syndrome, osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), age related osteoporosis (is a condition where the bones become weak and brittle, , making them easy to break), fracture of T9-T10 [ninth and tenth thoracic] vertebra (a broken bone in your mid-upper back), multiple rib fractures, fractured coccyx (broken tailbone), and a fracture of the distal left radius (broken wrist). During a review of Resident 6's MAR, the MAR indicated that Resident 6 was prescribed: Hydrocodone-Acetaminophen Oral Tablet 10-325 mg Give 1 tablet by mouth every 4 hours as needed for moderate to severe pain 4-10 start date 9/22/25 11:15 and discontinue [DC] date 11/21/25 16:49, and Residents Affected - Few 055454 Page 12 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Hydrocodone-Acetaminophen Oral Tablet 10-325 mg Give 1 tablet by mouth every 4 hours as needed for severe pain 7-10 Start Date 11/22/25 14:27, and Hydrocodone-Acetaminophen Oral Tablet 10-325 mg Give 1 tablet by mouth two times a day for severe pain 7-10 for 10 days start date 11/25/25 16:00. The MAR indicated Resident 6 was administered: Hydrocodone-Acetaminophen 10/325 give 1 tablet every 4 hours as needed for moderate to severe pain 4-10 Start date 9/22/25 11:15, DC Date 11/21/25 16:49 on:o 11/12/25 5:26 a.m. for pain 3/10 Hydrocodone-Acetaminophen 10/325 give 1 tablet every 4 hours as needed for severe pain 7-10, Start date 11/22/25 14:27:o 11/24/25 09:37 for pain 6/10o 11/25/25 04:09 for pain 4/10o 11/25/25 08:25 for pain 6/10o 11/27/25 01:46 for pain 5/10o 11/28/25 03:47 for pain 3/10 o 12/6/25 16:58 for pain 5/10 During a phone interview on 12/2/25 at 2:15 p.m. with the Licensed Vocational Nurse (LVN) 3, LVN 3 stated PRN (pro re nata meaning as needed) pain medication orders are written using a 0-10 pain scale, which identifies mild pain (1-3), moderate pain (4-7), and severe pain (8-10), with specific medications ordered for each level of pain severity. LVN 3 stated the LN was responsible for assessing the resident's pain score and administering the physician ordered pain medication corresponding to the resident's level of pain. LVN 3 stated the importance of administering PRN pain medications in accordance with physician's order was necessary to effectively manage residents' pain. LVN 3 stated failure to follow physician's orders could result in unmanage pain, negative impact on residents' daily functioning, or place residents at risk for overmedication. During a phone interview on 12/3/25 at 10:15 a.m. with LVN 5, LVN 5 stated for PRN pain medication administration, the LN would review the MAR to verify the timing of the last administered dose prior to giving the medication. LVN 5 stated the LN should administer the pain medication according to the resident's assessed pain level and as prescribed. LVN 5 stated if the resident reported moderate pain, the LN would administer pain medication specifically ordered for moderate pain. LVN 5 stated it was important to administer pain medication as prescribed and failure to administer pain medication according to physician's order could place residents at risk for medication errors, including potential overdose. During a concurrent interview and record review on 12/10/25 at 10:47 a.m. with the IP, Resident 5's MAR dated [DATE] was reviewed. The MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain, Tylenol 325 mg give 2 tab by mouth every 8 hours as needed for mild pain, Oxycodone 5mg give 1 tablets by mouth every 4 hours as needed for moderate pain and Oxycodone 5mg give 2 tablets by mouth every 4 hours as needed for severe pain. The MAR indicated Resident 5 was administered Oxycodone 5mg give 2 tablets for severe pain on: 11/2/25 05:15 for pain 4/10 (moderate pain) by LVN 1 11/3/25 01:56 for pain 3/10 (mild pain) by LVN 6 11/3/25 07:52 for pain 4/10 (moderate pain) by LVN 1 11/3/25 12:44 for pain 4/10 (moderate pain) by LVN 1 11/4/25 03:00 for pain 4/10 (moderate pain) by LVN 6 11/4/25 08:04 for pain 4/10 (moderate pain) by LVN 1 11/5/25 01:50 for pain 4/10 (moderate pain) by LVN 6 11/6/25 00:00 for pain 4/10 (moderate pain) by LVN 6 11/7/25 04:34 for pain 3/10 (mild pain) by LVN 6The IP stated that pain levels of 3 and 4 were not severe (7-10), and Resident 5 did not receive the appropriate medication. IP stated Resident 5 should have received Tylenol for mild pain 3/10 and oxycodone 5mg 1 tab for moderate pain 4/10. IP stated LVN 1 and LVN 6 who were assigned to Resident 5 did not follow the physician's order. IP stated the importance of administering medication as prescribed by the physician to avoid overmedication. IP stated overmedication could lead to serious harm, such as respiratory distress, since narcotics could suppress breathing, potentially causing a resident to experience a medical emergency and even death. During a concurrent interview and record review on 12/10/25 at 11:58 a.m. with LVN 1, Resident 5's MAR dated [DATE] was reviewed. The MAR indicated Pain: monitor for presence of pain every shift using scale 0-10. 0=No pain, 055454 Page 13 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 1-3=mild pain, 4-6=moderate pain, 7-9=severe pain, 10 =very severe/horrible/worst pain. The MAR indicated LVN 1 administered Oxycodone 5mg give 2 tablets by mouth every 4 hours as needed for severe pain on: 11/2/25 05:15 for pain 4/10 (moderate pain) 11/3/25 07:52 for pain 4/10 (moderate pain) 11/3/25 12:44 for pain 4/10 (moderate pain) 11/4/25 08:04 for pain 4/10 (moderate pain) LVN 1 stated the medication administered was not the correct dose per the pain scale score. LVN 1 stated based on the pain scale, the resident should not have been administered two tablets. LVN 1 stated if a resident reports a lower pain score, the LN should not administer the higher dose of pain medication. LVN 1 stated if a resident required any as needed pain medication, the LN would ask the resident for the pain level, based on the pain level the nurse would review the MAR to determine the appropriate medication to administer. LVN 1 stated it was important for the LN to adhere to the pain scale to prevent residents from taking unnecessary medication. LVN 1 stated a higher-than-necessary medication dose could place the resident at risk of an overdose. During a phone interview on 12/16/25 at 1:15 p.m. with the PHARM, the PHARM stated the facility should have a pain scale clearly associated with mild, moderate, and severe pain to ensure the decision of which medication to administer was guided by the physician orders rather than left to individual nurse judgement. The PHARM stated PRN medications should be administered by the physician's order to ensure proper pain management and avoid unnecessary medications. The PHARM stated failure to follow physician orders and unnecessary medication administration could lead to drowsiness, respiratory distress or respiratory depression and death. During a phone interview on 12/17/25 at 1:21 p.m. with the DON and ADM, the DON stated she expected the LN to follow the physician's orders when administering PRN pain medication. The DON stated the LN must assess the resident's pain score and match the pain score to the physician's corresponding pain medication order. The DON stated it was important to follow the physician's order to ensure residents receive the correct medication and are not administered unnecessary medications. The DON stated the risk of administering unnecessary medication could result in drug dependency in residents. During a review of the facility's P&P titled, Medication Administration dated 12/17/24, the P&P indicated .10. Ensure that the six rights of medication administration are followed: a. right resident, b. Right drug, c. Right dosage.f. Right documentation. During a review of the facility's policy and procedure titled, Pain Management, dated 12/17/2024, the P&P indicated Policy: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Pain Assessment: 2.c, Asking the patient to rate the intensity of his/her pain using a numerical scale.2.i. current prescribed pain medications, dosage and frequency.Pain Management and Treatment.7. Pharmacological interventions will follow a systematic approach for selecting medication and dosages to treat pain.7. a. Evaluate the resident's medical condition, current medication regimen, cause and severity of the pain and course of illness to determine the most appropriate analgesic therapy for pain. 7.e. Use lower doses of medication initially and titrate slowly upward until comfort is achieved.7. j. Facility staff will notify the practitioner, if the resident's pain is not controlled by the current regimen. During a review of the facility's P&P titled, PRN Medications dated 12/17/24, the P&P indicated adequate indications for use refers to the identified, documented clinical rational for administering a medication that is based upon an assessment of the resident's condition.adequate indication for use means that the medication administered is consistent with.clinical practice guidelines, clinical standards of practice.Policy Explanation and Compliance Guidelines:.3. When administering a PRN medication: a. Verify physician's order for the medication, b. Document the reason voiced by the resident and/or assessment findings.that verify the reason for the prescribed 055454 Page 14 of 15 055454 12/10/2025 Vineyards at Fowler 1306 East Sumner Avenue Fowler, CA 93625

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few indication for the medication, c. Document the time of administration. During a review of professional reference review retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC9039188/pdf/fphar-13-759998.pdf National Library of Medicine titled, Practical Considerations of PRN Medicines Management: An Integrative Systematic Review, dated 4/12/22 indicated .Pro re nata (PRN), when required, or as needed is defined as the prescription and administration of medications based on the immediate patients' needs instead of prescheduled administration times. the nurse responsibility to administer PRN medications based on the patient health condition after receiving the physician's prescription order (Dorks et al., 2019). Improper prescription and administration of PRN medications can cause medication interactions, adverse drug reactions (ADRs), overuse and abuse (Davies et al., 2007; Vaismoradi et al., 2018) . 055454 Page 15 of 15