Health inspection·May 20, 2025

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 observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) did not receive medication that is greater than the recommended dose by the manufacturer's label, and accepted standards of practice for a resident ' s condition. Residents Affected - Few This deficient practice had potential to cause adverse reactions and medical complications for Resident 1. Findings During a review of Resident 1 ' s admission Record dated 5/20/2025, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 1 ' s diagnoses included diabetes mellitus (DM- a condition characterized by difficulty in blood sugar control and poor wound healing), other specified disorders of bone density and structure (a variety of conditions that affect bone strength), and muscle weakness (when muscles are not as strong as they should be). During a review of Resident 1 ' s History and Physical (H&P) dated 1/9/2025, the H&P indicated Resident 1 was not able to make medical decisions. During a review of Resident 1 ' s Minimum Data Set (MDS– a resident assessment tool) dated 2/19/2025, the MDS indicated Resident 1 was usually able to understand and be understood by others. The MDS indicated Resident 1 required set up assistance to substantial/maximal assistance (staff does more than half the effort) for Activities of Daily Living (ADLS) such as bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed), transfers and walking. During a review of Resident 1 ' s Radiology Report dated 5/14/2025, the Report indicated Resident 1 had generalized osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D ) with degenerative disc space narrowing at all lumbar levels (a condition where the cartilage in the spine joints begin to wear out) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) change of the left hip joint. During a review of Resident 1 ' s Physician Order dated 5/14/2025, the Order indicated to administer Alendronate Sodium (a medication that slows the breakdown of bone and prevents the loss of calcium) 70 milligrams (mg-unit of measurement) 1 tablet by mouth in the morning for osteoporosis to Resident 1. Page 1 of 2 055737 055737 05/20/2025 Sunny Hills Post Acute 12200 LA Mirada Blvd. LA Mirada, CA 90638

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s Order Progress Note dated 5/14/2025, the Progress Note indicated the order for Alendronate Sodium was outside the recommended dose or frequency. The Progress Note indicated Alendronate Sodium oral tablet 70 mg. one tablet by mouth daily exceeded the usual dosing regimen of 0.5 tablet every seven days to 0.67 tablet daily. During a review of Resident 1 ' s Medication Administration Record (MAR) dated 5/2025, the MAR indicated Alendronate Sodium oral tablet 70 mg one tablet by mouth was administered to Resident 1 on 5/15/2025, 5/16/2025, and 5/18/2025. During a review of Resident 1 ' s Change of Condition (COC) dated 5/18/2025, the COC indicated. Alendronate 70 mg was ordered to be given every week on Saturdays but was entered as Alendronate 70 mg by mouth daily and Resident 1 was given Alendronate 70 mg on 5/15/2025, 5/16/2025, and 5/18/2025. During an interview on 5/20/2025 at 9:35 a.m. with Resident 1, Resident 1 stated she received new medication for osteoporosis and was supposed to take it weekly, but the nurses (not specified) administered it to her (Resident 1) twice last week. During a concurrent interview and record review on 5/20/2025 at 11:20 a.m. with the Director of Nursing (DON), Resident 1 ' s order Progress Note dated 5/14/2025 was reviewed. The DON stated licensed nurses should have caught the medication order alert sooner indicating the Alendronate Sodium exceeded the usual dosage and clarified the order with the NP or physician. During an interview on 5/20/2025 at 2:07 p.m. with the pharmacist (Pharm 1), Pharm 1 stated Alendronate Sodium 70 mg should be given once a week and not daily. Pharm 1 stated the pharmacy only sent four tablets so it should have alerted the nurses that the medication was for weekly and not daily dosing. Pharm 1 stated the medication packaging also had instructions for weekly dosing. Pharm 1 stated taking Alendronate over the recommended once weekly dose could cause overdosing and lead to constipation (problem passing stool), diarrhea (loose watery stool), abdominal pain, headache, and muscle cramps. During a concurrent record review and interview on 5/20/2025 at 3:25 p.m. with Registered Nurse (RN) 1, Resident 1 ' s Order Progress Note dated 5/14/2025 was reviewed. RN 1 stated she did not notice the medication alert on 5/14/2025 indicating the Alendronate Sodium dose for Resident 1 exceeded the usual dosing. RN 1 stated, if she had noticed the alert, she would have contacted the NP immediately to clarify the order. RN 1 stated, she became aware of the dosage error and reached out to the NP to clarify the order on 5/18/2025. RN 1 stated, the NP informed her, the Alendronate Sodium was supposed to be administered weekly (not daily) to Resident 1. During a concurrent observation and interview on 5/20/2025 at 4:00 p.m. with the DON, Resident 1 ' s Alendronate Sodium medication packaging/box was observed. The DON stated the medication packaging/box indicated the medication was to be given once weekly and nurses should have been aware of the instructions and administer the medication once weekly to Resident 1. During a review of the facility ' s policy and procedure (P&P) titled, Medication Errors, dated 12/19/2022, the P&P indicated the facility would ensure medications would be administered according to physician orders, per manufacturer ' s specifications regarding the preparation, and administration of the drug or biological, and in accordance with accepted standards and principles which apply to professionals providing services. 055737 Page 2 of 2