Health inspection·March 26, 2024

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. Based on observation, interview, and record review, the facility failed to provide routine medications for one of three sampled residents (Resident 1) when the resident's prescription medications were not refilled in a timely manner. This failure resulted in Resident 1 having withdrawal symptoms including unbearable pain, anxiety, and insomnia. Findings: Review of Resident 1's admission Record indicated the resident was a long-term resident in the facility with multiple diagnoses that included rheumatoid arthritis (RA, a chronic autoimmune disease that causes inflammation in the joints), low back pain and sideways curvature of the spine. In a concurrent observation and interview on 3/25/24 at 10:26 a.m., Resident 1 was sitting upright in her bed and stated she had RA. The resident's wrists were observed to be deformed and have healed surgical incisions over both wrists. Resident 1 voiced she did not receive her routine medications because somebody forgot to fill in her prescriptions and it caused her having gone through withdrawal for four days. The resident reported that she had pain that was horrible and unbearable and complained she was anxious, aching, aching during the time. Resident 1 stated she could hardly move, eat or sleep and indicated all her energy was gone during the withdrawal phase. Review of Resident 1's medical record, Medication Administration Record (MAR) for February and March 2024 indicated the resident had physician orders with the order dates as follows: 1. 11/16/22: Morphine Sulfate ER (Extended Release) 15 mg (milligram, a measurement) by mouth four times a day for chronic pain. 2. 10/8/23: Baclofen 5 mg by mouth twice a day for back spasm. 3. 4/9/23: Methotrexate Sodium 10 mg by mouth one time every Friday for RA In a concurrent interview and review of Resident 1's medical records, MARs and Nurses Notes, on 3/25/24 starting at 11:17 a.m. at the nursing station, Licensed Nurse (LN 1) verified Resident 1 did not receive the following medications due to the medications not being available for administration: 1. Morphine Sulfate ER 15 mg from 3/16/24 through 3/19/24, for a total of 11 times. Page 1 of 2 055497 055497 03/26/2024 The Pines at Placerville Healthcare Center 1040 Marshall Way Placerville, CA 95667

F 0755 2. Baclofen 5 mg on 3/15/25 (twice), 3/17/24 (twice), and 3/25/25 (once) for five times Level of Harm - Minimal harm or potential for actual harm 3. Methotrexate Sodium 10 mg on Friday, 2/23/24. Residents Affected - Some In a concurrent interview on 3/25/24 starting at 11:17 a.m. at the nursing station, LN 1 stated it was the facility policy for LNs to contact the pharmacy to reorder a week prior to the residents' medications running out. LN 1 acknowledged LNs had 28 opportunities (4/day x 7 days) to fill Resident 1's morphine sulfate and 14 opportunities (2/day x 7 days) for Baclofen. LN 1 stated LNs should have contacted the pharmacy to refill the medications. Review of the facility's policy and procedure, Medication Ordering and Receiving From Pharmacy, effective March 2018, stipulated, Medications .are received from the dispensing pharmacy on a timely basis .Reorder medication three to four days in advance of need to assure an adequate supply is on hand .Department of Veterans Affairs prescriptions, order at least seven days in advance of need. In a concurrent interview and record review on 3/25/24 at 12:33 p.m., the Director of Nursing (DON) verified the medication orders for Resident 1 and the missed doses and the dates. The DON stated Resident 1 did not receive her routine medications because the medications were not available for administration. The DON stated it was her expectations for LNs to start to refill either when they reached to a blue spot on each medication blister pack or at least three to four days before the medications ran out. The DON stated LNs should have reordered Resident 1's medications in a timely manner. 055497 Page 2 of 2