Health inspection·January 3, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure, one of four sampled residents (Resident 3), swallowed scheduled stool softener medications during medication administration. This failure resulted in Resident 3 missing a dose and placed the resident at risk for constipation. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including primary generalized osteoarthritis (a type of joint disease that causes breakdown of cartilage, the protective tissue that cushions the ends of bones in joints that affects multiple joints, including the hands, knees, hips, and spine) and chronic obstructive pulmonary disease ([COPD], a common lung disease causing restricted airflow and breathing problems). During a review of Resident 3's Minimum Data Set (Minimum Data Set [MDS] a standardized assessment and care screening tool), dated 12/12/2024, the MDS indicated Resident 3 had moderate cognitive (the ability to think and reason) impairment (a loss of part of all ability). The MDS indicated Resident 3 required substantial/maximal assistance (staff does more than half the effort) for Activities of Daily Living (ADLs) such as toileting hygiene (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement) and showering/bathing self. During a review of Resident 3's Order Summary Report, dated 12/31/2024, Resident 3's physician orders indicated, Docusate Sodium Oral Tablet 100 milligrams ([mg], a unit of measurement), give two tablets by mouth two times a day for bowel management. Hold if loose stools. During a concurrent observation and interview on 12/31/2024 at 10:00 a.m. with Resident 3 at Resident 3's bedside, two small sized, white, circular pills inside a plastic cup, on top of Resident 3's bedside table were observed. Resident 3 stated the pills were stool softeners (a medication to help with bowel movements). Resident 3 stated she was instructed by the nurse (not identified) to take the pills this morning (12/31/2024). During a concurrent observation and interview on 12/31/2024 at 10:14 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was shown a photo of Resident 3's stool softeners inside a plastic cup at Resident 3's bedside table. LVN 1 stated, Resident 3 did not take the pills. LVN 1 stated the facility did not ensure Resident 3 took all her medications. Page 1 of 2 055737 055737 01/03/2025 Sunny Hills Post Acute 12200 LA Mirada Blvd. LA Mirada, CA 90638

F 0755 Level of Harm - Minimal harm or potential for actual harm During an interview on 12/31/2024 at 10:33 a.m., LVN 2 stated it was not appropriate to leave medication at a resident's bedside. LVN 2 stated leaving medications at a resident's bedside is not the proper administration of medications. LVN 2 stated leaving medications at a resident's bedside placed other residents at risk of taking medication not ordered for them. LVN 2 stated, the resident could have missed taking the medication, if they were just left at the bedside. Residents Affected - Few During a concurrent record review and interview on 12/31/2024 at 2:43 p.m. with the Director of Nursing (DON), Resident 3's admission assessments and photo of Resident 3's bedside table with pills, were reviewed. The DON stated nurses should ensure residents ingest or swallow all medications given during medication administration process. The DON stated, It was not acceptable to leave pills at resident's bedside. The DON stated if any residents can self-administer medications, they should have been assessed upon admission. The DON stated Resident 3's admission assessments did not indicate Resident 3 could self-administer medication. During a review of facility's policy and procedure (P&P) titled, Medication Administration, dated 12/19/2022, the P&P indicated, the licensed nurses should observe resident consume the medication. 055737 Page 2 of 2