Health inspection·August 31, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three medications were administered to the appropriate resident for one of three residents (Resident 1). This failure had the potential to affect Resident 1's respiratory function and overall health and safety. Residents Affected - Few Finding: An abbreviated survey was conducted on August 4, 2023, at 11:20 AM to investigate a complaint related to quality of care. During a review of Resident 1's clinical record, the face sheet indicated Resident 1 was admitted on [DATE], with diagnoses, which included Myocardial Infarction (Heart attack), Cerebral Vascular Accident (an interruption in the flow of blood to cells in the brain). During review of the clinical record for Resident 1, the Incident Note dated July 30, 2023, at 2:08 pm by the Director of Nursing (DON) indicated, Notified by RN regarding administering another residents' medications (Hydromorphone 4mg (a powerful pain killer), Cymbalta 60mg (used for treatment of depression and anxiety), and baclofen 20mg (a muscle relaxant). During an interview and concurrent record review of Resident 1's clinical records with the DON on August 4,2023, at 1:44 PM, DON stated, (Resident 1) was mistakenly given medication that belonged to another resident. She stated Licensed Vocational Nurse (LVN 1) misidentified the patient and gave him another residents medications. LVN1 came to me and notified me then we called the MD and per his orders started hourly vitals and continued observations on him for 48 hours. When asked if the patients had any negative side effects of the incorrect medications she stated, No he was fine he was a little sleepy, but his vital signs were normal, and he was okay we documented all our vitals and observations. The DON further stated, the staff are expected that it is the right med, right route, right dose, right indication, right patient. They can identify the patient by room number and patient picture and name in Point Click Care (PCC) (an Electronic Health record used by Skilled nursing facilities) some patients also have name tags/ bracelets. When asked if LVN 1 followed proper process for administering medication she stated, No she did not, she would have been able to tell the patients was the wrong one if she had verified with the picture on PCC, or if she was still unsure ask another nurse familiar with the patient. When asked what could happen if patients are given the wrong medication she stated, A lot of medication interactions could happen if the patients are given wrong medications, it depends on the (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 2 Event ID: 055557 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 055557 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/31/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Creekside Post Acute 35253 Avenue H Yucaipa, CA 92399 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)