Health inspection·October 17, 2024

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 3) was free from the unnecessary drugs. Residents Affected - Few * The facility failed to ensure Resident 3's metoprolol tartrate (a beta-blocker, a medication a medication that works by affecting the nerve impulses in the body such as the heart and slows the heartbeat and decreases blood pressure) and hydralazine (medication used to treat high blood pressure) were administered as per the physician's orders. This failure had the potential for the resident to receive unnecessary medications and develop significant side effects. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with prescriber orders, including any required time frame. Medical record review for Resident 3 was initiated on 10/17/24. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed the following physician's orders: - On 2/16/22, to administer metoprolol tartrate 25 mg one tablet orally two times a day for HTN and to hold if SBP less than 110 mmHg or HR less than 60 beats per minute; and - On 2/16/22, to administer hydralazine HCl 100 mg one tablet orally three times a day for HTN, and to hold if SBP less than 110 mmHg. Review of Resident 3's eMAR for October 2024 showed Resident 3 was administered the following medications: - The metoprolol medication was administered on 10/12/24 at 0600 hours, with the BP (blood pressure) of 105/54 mmHg, 10/13/24 at 0600 hours, with the HR of 55, and on 10/13/24 at 1800 hours, with the HR of 55 beats per minute. - The hydralazine medication was administered on 10/11/24 at 1400 hours, with the BP of 106/55 mmHg. Review of Resident 3's plan of care showed a care plan problem initiated on 7/27/24, addressing Resident 3's hypertension. The interventions included to check and verify the vital signs for each resident prior to their medication administration if necessary. On 10/17/24 at 1515 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 verified the above findings. LVN 1 stated the blood pressure medications were not administered per the physician's orders and parameters. LVN 1 stated upon administering the blood pressure medications, the blood pressures were checked, and the results were compared with the ordered parameter. LVN 1 stated administering the blood pressure medications outside of the ordered parameters could further lower the resident's blood pressures and/or heart rates and lead to negative outcomes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055674 If continuation sheet Page 2 of 3 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 055674 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Healthcare Center of Orange County 9021 Knott Ave Buena Park, CA 90620 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)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete On 10/17/24 at 1610 hours, an interview was conducted with the DON. The DON stated the nurses administering the blood pressure medications were expected to read the physician's orders and administer the medications as ordered. On 10/17/24 at 1615 hours, an interview was conducted with the AIT and DON. The AIT and DON acknowledged the above findings. Event ID: Facility ID: 055674 If continuation sheet Page 3 of 3