Health inspection·March 11, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a routine medication was available for one of three sampled residents (Resident 1). This failure resulted in Resident 1 not receiving scheduled medication and caused the resident distress. Findings: During an interview on 3/7/25 at 3:40 p.m. with the director of nursing (DON), the DON stated Resident 1 was admitted on [DATE] at 5:30 p.m. The list of medications was sent electronically to the pharmacy and the facility eventually received delivery of the medications from the pharmacy. Missing from the medications was Alprazolam (medication for anxiety) 2 mg (milligrams). Resident 1 takes Alprazolam 2 mg. at bedtime routinely. During a telephone interview on 3/7/25 at 4:20 p.m. with the pharmacist, the pharmacist stated all controlled medications need to be faxed to the pharmacy. The facility can send medication requests, even controlled medications electronically but a fax still needs to be sent for any controlled medication. The only exception for not sending a fax for a controlled medication is when the doctor/prescriber sends the order electronically directly to the pharmacy. During an interview on 3/7/25 at 4:50 p.m. with admitting nurse (LN 1), LN 1 stated admitted Resident 1 on 3/4/25 at 5:30 p.m., reconciled the medications, sent the medication list electronically to the pharmacy and called the pharmacy to confirm they received the requested medication list sent. LN 1 admitted was not aware a fax had to be sent for the controlled medication, Alprazolam 2 mg. During a review of Resident 1's Nursing Progress Notes (Notes), dated 3/4/25 at 10:42 p.m., the Notes indicated, LN 2 documented, Medication did not arrive with pharmacist sender. Will call and get information on it . There were no further updates/documentation regarding the missing Alprazolam or attempt to call the physician to request an alternative medication. During a review of Resident 1's Notes, dated 3/5/25 at 10:56 p.m., LN 4 documented, Patient was upset Alprazolam wasn't here. This writer explained to pt (patient) that I will call pharmacy for ETA (Estimated Time of Arrival) of med.(medication) MD notified requesting alternative med d/t (due/to) Alprazolam not available. Resident 1's Representative was very upset and signed Resident 1 out of the facility AMA (Against Medical Advise) on 3/5/25 at 10 p.m. Page 1 of 2 055563 055563 03/11/2025 Santa Maria Post Acute 820 West Cook Street Santa Maria, CA 93458

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/7/25 at 4:55 p.m with the DON, the DON stated LN 2 called the pharmacy to follow up on the medications. Pharmacy did not respond since it was close to midnight. LN 2 gave report to oncoming nurse, LN 3 (day shift [7A - 7P]) to follow up with the pharmacy. LN 3 did not document any follow up with pharmacy. LN 4 documented on 3/5/25 at 10:56 p.m., that Resident 1's Alprazolam 2 mg has still not been delivered by pharmacy. When DON was asked why LN 1 was unaware of faxing an order for controlled medication(s), why LN 2 & 3 did not call the doctor to request an alternate medication (Ativan) which was available in the e-kit, the DON did not have an answer. During a review of the facility's policy and procedure (P&P) titled, Ordering and Receiving Controlled Medications, dated 2023, the P&P indicated in part, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the facility, in accordance with federal and state laws and regulations. And C. New and refill orders for controlled medications are ordered as detailed in the procedure for Ordering and Receiving Medications from Dispensing Pharmacy. When a physician's signature is needed to validate a controlled drug refill, a facility specific Control Drug Order form can be completed by the physician or physician's agent, signed by the physician and faxed to the pharmacy. 055563 Page 2 of 2