Health inspection·April 5, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to implement their Policies and Procedures (P&P) related to administering and storage of medications. Upon a random, initial tour round, a medicine cup with six pills was observed on Resident's 2 overbed table while he was asleep. In addition, a opened bottle of Acetaminophen (Tylenol, a pain medication) was on top of a medication cart with no nursing staff nearby and a resident sitting near the medication cart. These failures had the potential to cause harm by allowing other residents the opportunity to access unattended medications. Findings: 1. On 4/5/2023 at 9:25 a.m., during initial tour rounds, two clear medicine cups were observed on Resident 2's overbed table while he had his eyes closed. One medicine cup had six different color medications in it and one medicine cup had a small amount of white fluid in it. At 9:29 a.m., RN A entered the room and told Resident 2 she needed to take his blood pressure. When she was asked the reason Resident 2's medications where left unattended on his overbed table, she stated the resident was in the shower when she placed the medication cups on his overbed table. RN A stated the medications should have not been left on Resident 2's overbed table if he was not available to administer the medications. Clinical record review for Resident 2 was initiated on 4/5/2023. Resident 2 was admitted to the facility with diagnoses including Metabolic Encephalopathy (damage or disease that affects the brain) and Dysphagia (swallowing difficulty). Review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 2/17/2023 showed a Brief Interview for Mental Status (BIMS) score of 12 (moderate cognitive impairment). Review of Resident 2's physician orders from 2/12/2023 - 4/5/2023, showed no order to leave his medications at his bedside. Review of Resident 2's care plan problems indicated the following: a. impaired swallowing related to dysphagia (revised date 2/12/2023); b. altered thought process related to short term memory problem-cannot recall after 5 minutes and periods of forgetfulness (revised date 2/21/2023); and Page 1 of 3 055517 055517 04/05/2023 Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032

F 0761 c. at risk for injury related to increased confusion (revised date 3/14/2023). Level of Harm - Minimal harm or potential for actual harm Review of Resident 2's Medication Administration Record (MAR) showed Registered Nurse (RN) A had initialed as being given at 9 a.m. on 4/5/2023: Residents Affected - Few a. Aspirin (medication to reduce heart attack) chewable 81 milligrams (mg, unit of measurement) by mouth; b. Cholecalciferol tablet (supplement) 1000 units, one tablet by mouth; c. Cyanocobalamin tablet (vitamin B-12, supplement) 100 micrograms (mcg) by mouth; d. Famotidine (medication gastrointestinal prophylaxis) tablet 20 mg by mouth; e. Folic Acid (supplement) tablet 1 mg by mouth; f. Midodrine HCL (blood presure medication) 5 mg by mouth for g. Megestrol Acetate (Megace, appetite stimulant) oral suspension (liquid) 400 mg/10 milliliters (ml), give 10 ml by mouth. On 4/5/2023 at 11:15 a.m., an interview was conducted with Certified Nursing Assistant (CNA) B. She stated Resident 2 gets a little bit disoriented in the mornings. CNA B confirmed she had given Resident 2 a shower earlier this morning and when the resident returned to his room, she observed the nurse had left his medications on the overbed table. 2. Another observation on 4/5/2023 at 9:32 a.m., showed an open bottle of Acetaminophen 325 mg containing multiple tablets, was on top of a medication cart located in the hallway at the Nurses' Station. A resident was sitting in her wheelchair across the Nurses' Station. There was no licensed nurse was visible at or around the Nurses' Station. As the Administrator was walking by, this Surveyor brought the opened bottle of Acetaminophen on top of the medication cart. He picked up the medication and stated the medication should not have been there. During an interview on 4/5/2023 at 11:40 a.m., the Director of Nursing (DON) stated Resident 2 was alert with periods of forgetfulness. She stated Resident had never requested to self-administer his medications. The DON stated the nurse should not have left Resident 2's medications at his bedside if the resident was not there. In addition, she stated the open bottle of Acetaminophen should not have been left on the medication cart, unattended. Review of the facility's Policy and Procedure (P&P) titled Administering Medications (revised date December 2012) showed for residents not in their room or otherwise unavailable to receive medication on the pass, the Medication Administration Record (MAR) may be flagged. After completing the medication pass, the nurse would return to the missed resident to administer the medication. The resident may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. Review of the facility's P&P titled Storage of Medications (revised date April 2007) showed Compartments containing drugs and biologicals shall be locked when not in use and items shall not be left 055517 Page 2 of 3 055517 04/05/2023 Woodlands Healthcare Center 14966 Terreno DE Flores Lane Los Gatos, CA 95032

F 0761 unattended if open or otherwise potentially available to others. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055517 Page 3 of 3