Health inspection·November 18, 2025

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. 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 necessary care monitoring, and interdisciplinary (IDT) coordination to prevent respiratory depression (hypoxia and loss of consciousness) and excessive sedation, when administrating multiple central nervous system (CNS) depressant medications (mirtazapine a medication for depression/mood, oxycodone a strong pain-relieving medicine, and alprazolam a medication for anxiety) for one of three sampled residents (Resident 1).This had the potential for Resident 1 to experience a significant decline in respiratory status from hypoxia.Findings:A review of Resident 1's admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease causing difficulty in breathing) and was transferred to a higher level of care on 3/18/23 related to lethargy (drowsiness) and respiratory distress (shortness of breath [SOB], low oxygen levels (below 90%), use of accessory muscles (using muscles in your neck, chest, and stomach to help you breathe). On 10/15/25 a review of Resident 1's clinical chart was conducted: Resident 1's care plan for anxiety (excessive worry, fear and nervousness) medication .Xanax [brand name of Alprazolam] . with a black box warning (the strongest warning the U.S. FDA can issue for a prescription drug, alerting healthcare providers and patients to the risk of serious or life-threatening adverse reactions) initiated 3/9/23, indicated, .Concomitant [simultaneous or successive use of two or more drugs] use of benzodiazepines and opioids may result in profound sedation, respiratory depression, coma, and death. Reserve concomitant prescribing of these drugs in patients for whom alternative treatment options are inadequate. Limit dosages and durations to the minimum required. Follow patients for signs and symptoms of respiratory depression and sedation. Per the Acute Hospital Records dated 3/7/23, indicated .chronic hypoxic (low oxygen) respiratory failure with COPD, on 3 to 4 L of home oxygen.A review of the admission assessment dated , 3/8/23 titled, admission Drug Regimen Review indicated, Possible drug interaction(s) or duplicate therapy was identified after pharmacy orders are entered in the system. was answered No. The New admission Medication Regimen Review medication regimen review (MRR-pharmacy review recommendations) dated, 3/8/25 indicated, .Recommendations.Drug interactions.MD Notified No. A review of the Progress note Medication Regimen Review dated, 3/9/2023 at 17:05 (5:05 P.M.) indicated, .Received new admission MRR from [facility Pharmacy Vender Name] with recommendations from pharmacist to monitor for CNS depression due to alprazolam, mirtazapine, and oxycodone pain medication that can cause CNS depression]. Review of the Change in Condition [COC] notes was conducted. The COC note dated, 3/13/2023 21:22 (9:22 P.M.) indicated, Other change in condition positive covid [COVID- a highly contagious virus that infects the respiratory system to cause SOB, respiratory distress and death] .The COC note dated 3/14/23 17:00 (5 P.M), indicated, .At approximately 1700 the patient had hypoxia and an O2 saturation of 54%.There was no documented evidence of physician's notification regarding MRR Pharmacy recommendations with Resident 1's medications (Alprazolam, Mirtazapine, and Residents Affected - Few Page 1 of 3 055632 055632 11/18/2025 Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Oxycodone) for clarification, parameters, and/or monitoring of CNS depression. In addition, there was no interdisciplinary team (IDT) documented to address Resident 1's change of condition. A review of the Medication Administration Record (MAR) dated, 3/17/23 indicated, .ALPRAZolam Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth as needed for ANXIETY BID [twice daily] . was given to Resident 1 at 2011(8:11 P.M.).oxyCODONE HCl Oral Tablet 10 MG (Oxycodone HCl) Give 2 tablet mouth every 4 hours as needed for SEVERE PAIN. was given to Resident 1 at 2128 (9:28 PM). A review of the COC note dated 3/17/2023 10:30 (P.M.), indicated, .Shortness of breath Other change in condition HYPOXIA/LETHARGY.02 [oxygen] 73 % .Date and time of clinician notification:03/17/2023 10:50 PM.The COC note dated 3/18/2023 00:30 (12:30 A.M.), indicated, .Pt noted to be lethargic and still having increased SOB, O2 sat is 70% on 3L/min via NC, condition rapidly declined, use of accessory muscle with breathing. Pt [patient] repositioned on. High Fowler's (a position in which the individual lies on their back with the head of bed elevated at 30-45 degrees), O2 sat ranging from 96-97% on non-rebreather mask @ 8L/min at around 2330. MD notified, advised to call 911. On 10/25/25, a record review was conducted on Resident 1's clinical chart. Resident 1's post respiratory vital signs (oxygen levels and respirations) after medications (alprazolam, oxycodone and mirtazapine) were administered indicated:- 3/13/23 all three medications given, alprazolam 0.25 milligrams (mg) given at 2300 (11 P.M.) mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2111 (9:11 P.M.) No respirations, or oxygen levels was taken after alprazolam within one hour of administration.3/14/23 all three medications given, alprazolam 0.25 mg given at 2024 (8:24 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2123 (9:23 P.M.). No respirations, or oxygen levels was taken after alprazolam within one hour of administration.- 3/15/23 all three medications given, alprazolam 0.25 mg given at 2055 (8:55 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg at 2239 (10:39 P.M.). No respirations, or oxygen levels were taken after each medication within one hour of administration for two medications (alprazolam and mirtazapine).-3/16/23 all three medications given, alprazolam 0.25 mg given at 2014 (8:14 P.M.) mirtazapine 15 mg given at 2100 (9 P.M.) and oxycodone 20 mg given at 2150 (9:50 P.M.). No respirations, or oxygen levels were taken after each medication (mirtazapine and oxycodone) within one hour of administration for all three medications.- 3/17/23 all three medications given, alprazolam 0.25 mg given at 2011 (8:11 P.M.), mirtazapine 15 mg given at 2100 (9 P.M.), and oxycodone 20 mg given at 2128 (9:28 P.M.). No respirations, or oxygen levels were taken after each medication (alprazolam, mirtazapine, and oxycodone) within one hour of administration. On 10/15/25 at 11:45 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated Resident 1 was not on Hospice. The ADON stated while in the facility Resident 1 continued with rehab services for occupational therapy (OT) and physical therapy (PT). The ADON stated Resident 1 had malignant rectal cancer (harmful tumor of the rectum) and was treated with radiation/chemo and immunotherapy. On 10/16/25 at 11:05 A.M., an interview and record review were conducted with LN 1. LN 1 stated she was a nurse supervisor that reviews the MRR. LN 1 stated Resident 1 had an MRR dated 3/8/23 to monitor CNS depression because Resident 1 was on medications (Alprazolam, Mirtazapine and oxycodone) that can cause CNS depression to include respiratory distress. LN 1 stated CNS depression on the MRR was vague and was not clarified with the Pharmacist nor physician notified of recommendation as to what should be monitored when all three meds were given because taking three medications (Alprazolam, Mirtazapine and oxycodone), knowing Resident 1's history of respiratory disease and COVID would enhance the incidence of Respiratory depression. On 10/16/25 at 12:28 P.M., an interview and record review were conducted with ADON. The ADON stated they did not have a written policy and procedure for monitoring facility residents who was on several sedating medications. ADON agreed 055632 Page 2 of 3 055632 11/18/2025 Grossmont Post Acute Care 8787 Center Drive LA Mesa, CA 91942

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the care plan was not updated to address CNS depression as recommended per the MRR. The ADON stated the MRR recommendation for CNS depression monitoring was vague and should have been clarified with Resident 1's physician because monitoring for Resident 1's respiratory status should have included the respiratory rate, and oxygen saturation levels. On 10/20/25 at 10:15 A.M., an interview and record review were conducted with the Pharmacist (Pharm). The Pharm stated Resident 1 was receiving meds for COPD and given her history, Resident 1 had medications for depression (Mirtazapine) to control her depression. The Pharm stated she would not recommend stopping Mirtazapine for depression management but would have questioned the Alprazolam and the Oxycodone which were two medications that were short-acting medications (fast onset works within 20-30 minutes to work) that could cause a higher risk for CNS depression. The Pharm stated it would be best for a different class of anti-anxiety medication from a different class that did not interact with opiate medication to minimize the CNS depression. The Pharm stated Resident 1's history of COPD and COVID monitoring for respiratory distress would need to be assessed more often before and after administration of combined medications of Oxycodone and Xanax. On 10/20/25 at 2:14 P.M, an interview was conducted with the Medical Director (MD). The MD stated the combination (oxycodone, mirtazapine, and alprazolam) could cause central nervous system (CNS) depression and respiratory distress. The MD stated if there were any signs of CNS depression during a COC while on narcotic (drugs that are controlled because of their potential for abuse) medications (oxycodone and alprazolam) the nursing staff should notify the assigned physician, and if unable to get a hold of the assigned physician, to notify him. The MD stated, in general if there is CNS depression not responding (not talking, not responding to pain) then Narcan would be recommended but if a resident (any residents) was with it (alert and able to respond), then oxygen administration would be recommended. The MD stated it was professional standards of practice to monitor before and after vital signs (blood pressure, heart rate, respiration rate, and oxygen levels) during medication administration. The MD stated vital signs should be monitored after each medication within one hour of administration. On 10/20/25 at 3:06 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated the MRR recommendations from the Pharm was vague and was not specific to what needed to be monitored for CNS depression when taking the medications (Alprazolam, Mirtazapine, and Oxycodone). The DON stated it was important when giving medications to have clear instructions to follow as part of Resident 1's specific plan of care to monitor for CNS depression to include lethargy, increased sedation and vital signs before and after administration according to professional standards of practice of high-risk (addictive/life-threating) medications such as Oxycodone and Xanax. According to the Centers for Disease Control and Prevention (CDC), 11/28/22 SUDORS Manual Version 6.3 at https://www.cdc.gov/overdose-prevention/media/pdfs/2025/02/SUDORS_Coding_Manual_OD2A_v6.3b_Feb2025.pdf .Since opioids [ a controlled medication class such as Oxycodone] can cause respiratory depression, having a pulmonary (lung) condition such as COPD can put someone at risk for opioid-involved overdose . A review of the facility's policy and procedure titled, Significant Change in Condition, Monitoring for (Undated), indicated .The IDT shall collaborate with the Attending Physician, Resident, and/or Resident Representative to review risk indicators and the plan of care as well as document this collaboration in the EMR [electronic medical record] in the next scheduled Comprehensive Care Plan Meeting or sooner if deemed necessary by the IDT . 055632 Page 3 of 3