Health inspection·January 15, 2025

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to follow their policies and procedures (P&P) titled, Psychotropic Medication Use,regarding the safe and appropriate prescribing and administering of psychotropic (used to treat psychosis- conditions that affect the mind, where there has been some loss of contact with reality) medication for one of five sampled residents (Resident 1) when Divalproex sodium (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and mental disorders and to prevent migraine headaches) was prescribed and administered prior to determining the appropriate indication for use. This failure increased Resident 1 ' s risk of serious side effects that included but were not limited to nausea, vomiting, headaches, liver complications, tardive dyskinesia (condition causing uncontrolled movements various body parts like the arms and legs or of the tongue in a chewing motion) and changes to mood, behaviors and thought processes. Findings: During a review of Resident 1 ' s admission Record (AR- a document that provides resident contact details, a brief medical history), dated 1/15/25, the AR indicated, Resident 1 had diagnoses which included .VASCULAR DEMENTIA [decline in thinking, memory and judgement caused by an impaired supply of blood to the brain] .ANXIETY DISORDER [mental condition which causes intense and persistent worry] .CEREBRAL INFARCTION [a serious condition that occurs when blood flow to the brain is blocked causing damage to the tissue] .APHASIA [disorder affecting one ' s ability to communicate] .HISTORY OF TRANSIENT ISCHEMIC ATTACK [TIA- a temporary lack of blood flow to the brain] . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 1/4/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation, and memory recall) indicated a score of 6 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment. During a review of Resident 1 ' s Hospitalist Discharge Summary (HDS), dated 1/3/25, the HDS indicated, .past medical history significant for hypertension [high blood pressure], TIA, anxiety .and reported dementia who was brought to the ED [emergency department] (as a code stroke) on 12/30/2024 for slurred speech and confusion .and no reported history of seizures . During a concurrent interview and record review on 1/15/25 at 11:00 a.m. with Registered Nurse (RN) Page 1 of 5 055869 055869 01/15/2025 Valley Skilled Nursing Center 515 East Orangeburg Avenue Modesto, CA 95350

F 0758 Level of Harm - Minimal harm or potential for actual harm 2, Resident 1 ' s Order Summary Report (OSR), dated 1/3/25 was reviewed. The OSR indicated, . [Divalproex sodium] Oral Tablet Delayed Release 250 [milligram (MG - unit of measurement)] Give 1 tablet by mouth one time a day for seizure prevention . [Divalproex sodium] Oral Tablet Delayed Release 250 MG Give 2 tablet by mouth one time a day for seizure prevention . RN 2 stated, a possible side effect of Divalproex sodium were symptoms of tardive dyskinesia. Residents Affected - Few During a concurrent interview and record review on 1/15/25 at 2:10 p.m. with the Director of Nursing (DON), Resident 1 ' s Medication Administration Record (MAR), dated 1/15/25 was reviewed. The MAR indicated, .[Divalproex sodium] Oral Tablet Delayed Release 250 MG .Give 1 tablet by mouth in the afternoon for seizure prevention -Order Date- 01/03/2025 [4:51 p.m.] - [discontinue (D/C)] Date- 01/05/2025 [10:49 a.m.] .[Divalproex sodium] Oral Tablet Delayed Release 250 MG . Give 2 tablet by mouth one time a day for seizure prevention -Order Date- 01/03/2025 [4:51 p.m.] -D/C Date- 01/05/2025 [10:49 a.m.] . The MAR indicated, Divalproex sodium was administered to Resident 1 on 1/4/25 at 9:00 a.m., 1/4/25 at 4:00 p.m. and 1/5/25 at 9:00 a.m. The DON stated, Divalproex sodium was administered to Resident 1 for seizure prevention on 1/4/25 at 9:00 a.m., 1/4/25 at 4:00 p.m. and 1/5/25 at 9:00 a.m. The DON stated, Resident 1 was not diagnosed with any seizure disorder. The DON stated, it was important to have the correct indication for use listed for Resident 1 ' s order for Divalproex sodium because otherwise it was an unnecessary medication and there was not a valid reason to administer it to Resident 1. The DON stated possible side effects of Divalproex sodium included gastrointestinal distress, headaches, and liver complications. The DON stated, Divalproex sodium potentially altered Resident 1 ' s behavior, mood and thought processes. During a phone interview on 1/16/25 at 4:32 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1 ' s Inter-Facility Transfer Report (IFTR), was provided by the hospital to indicate which orders, including medications, Resident 1 should have continued upon admission to the facility. LVN 1 stated she administered Divalproex sodium on 1/5/25 at 9:00 a.m. to Resident 1 according to the medication orders. LVN 1 stated Resident 1 ' s responsible party (RP) asked for Divalproex sodium to be discontinued. LVN 1 stated she called Resident 1 ' s nurse practitioner (NP) and the NP ordered for the Divalproex sodium to be discontinued. During a phone interview on 1/17/25 at 3:00 p.m. with LVN 2, LVN 2 stated Divalproex sodium was prescribed to individuals as an anticonvulsant (to prevent seizures) medication and was also indicated to be used as a psychotropic medication. LVN 2 stated, it was important to administer the right medication with the appropriate indication according to the documented diagnoses of an individual. LVN 2 stated nurses should not administer an unnecessary medication like Divalproex sodium if Resident 1 did not have an appropriate diagnosis. During a phone interview on 1/17/25 at 3:45 p.m. with LVN 3, LVN 3 stated Resident 1 ' s RP was worried during a visit with Resident 1 on 1/4/25 because Resident 1 ' s mood was different than her usual self. LVN 3 stated Resident 1 ' s RP was upset after finding out Resident 1 was given Divalproex sodium because Resident 1 had not taken Divalproex sodium for a long time. LVN 3 stated a medication should only be given to Resident 1 for an appropriate diagnosis and not unnecessarily because there was a potential for Resident 1 to experience side effects. During a review of the facility ' s document titled, Psychotherapeutic [relating to the treatment of mental illness] Medication INFORMED CONSENT (PMIC), undated, the PMIC indicated, .MISCELLANEOUS MEDICATIONS . Depakote . DOCUMENTATION NEEDED IN CHART .Diagnosis and target behavior indicated in the medication order . 055869 Page 2 of 5 055869 01/15/2025 Valley Skilled Nursing Center 515 East Orangeburg Avenue Modesto, CA 95350

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the Mayo Clinic website, https://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/description/drg-20072886, dated 8/31/24, the website indicated, .Divalproex sodium .is used to treat certain types of seizures .also used to treat the manic (extremely elevated and excited mood) phase of bipolar (mental illness that causes intense shifts in mood, energy levels and behavior) disorder .elderly patients are more likely to have unwanted effects . Liver problems may occur while .using this medicine, and some may be serious .Side Effects .Confusion .Delusions (a false belief or judgement about external reality, despite evidence, occurring in mental conditions) of persecution, mistrust, suspiciousness, or combativeness .False beliefs that cannot be changed by facts .False or unusual sense of well-being .Headaches .Nausea .Problems with memory or speech .Rapidly changing moods .Sleepiness or unusual drowsiness .Trouble thinking and planning .Uncontrolled chewing movements .Uncontrolled movements of the arms and legs .Vomiting . During a review of the facility ' s P&P titled, Psychotropic Medication Use, 7/22, the P&P indicated, .Residents will not receive medications that are not clinically indicated to treat a specific condition .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use .Situations which may prompt an evaluation .of the resident include: a. admission .The evaluation may include .an evaluation of resident status (co-morbid conditions, symptoms, psychiatric diagnoses; etc.) . Based on interview and record review, the facility failed to follow their policies and procedures (P&P) titled, Psychotropic Medication Use ,regarding the safe and appropriate prescribing and administering of psychotropic (used to treat psychosis- conditions that affect the mind, where there has been some loss of contact with reality) medication for one of five sampled residents (Resident 1) when Divalproex sodium (medication used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and mental disorders and to prevent migraine headaches) was prescribed and administered prior to determining the appropriate indication for use. This failure increased Resident 1's risk of serious side effects that included but were not limited to nausea, vomiting, headaches, liver complications, tardive dyskinesia (condition causing uncontrolled movements various body parts like the arms and legs or of the tongue in a chewing motion) and changes to mood, behaviors and thought processes. Findings: During a review of Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history) , dated 1/15/25, the AR indicated, Resident 1 had diagnoses which included .VASCULAR DEMENTIA [decline in thinking, memory and judgement caused by an impaired supply of blood to the brain] .ANXIETY DISORDER [mental condition which causes intense and persistent worry] .CEREBRAL INFARCTION [a serious condition that occurs when blood flow to the brain is blocked causing damage to the tissue] .APHASIA [disorder affecting one's ability to communicate] .HISTORY OF TRANSIENT ISCHEMIC ATTACK [TIA- a temporary lack of blood flow to the brain] . During a review of Resident 1's Minimum Data Set (MDS- a standardized assessment and care screening tool) , dated 1/4/25, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS- an evaluation of attention, orientation, and memory recall) indicated a score of 6 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had severe cognitive impairment. 055869 Page 3 of 5 055869 01/15/2025 Valley Skilled Nursing Center 515 East Orangeburg Avenue Modesto, CA 95350

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's Hospitalist Discharge Summary (HDS) , dated 1/3/25, the HDS indicated, .past medical history significant for hypertension [high blood pressure], TIA, anxiety .and reported dementia who was brought to the ED [emergency department] (as a code stroke) on 12/30/2024 for slurred speech and confusion .and no reported history of seizures . During a concurrent interview and record review on 1/15/25 at 11:00 a.m. with Registered Nurse (RN) 2, Resident 1's Order Summary Report (OSR) , dated 1/3/25 was reviewed. The OSR indicated, . [Divalproex sodium] Oral Tablet Delayed Release 250 [milligram (MG - unit of measurement)] Give 1 tablet by mouth one time a day for seizure prevention . [Divalproex sodium] Oral Tablet Delayed Release 250 MG Give 2 tablet by mouth one time a day for seizure prevention . RN 2 stated, a possible side effect of Divalproex sodium were symptoms of tardive dyskinesia. During a concurrent interview and record review on 1/15/25 at 2:10 p.m. with the Director of Nursing (DON), Resident 1's Medication Administration Record (MAR) , dated 1/15/25 was reviewed. The MAR indicated, .[Divalproex sodium] Oral Tablet Delayed Release 250 MG .Give 1 tablet by mouth in the afternoon for seizure prevention -Order Date- 01/03/2025 [4:51 p.m.] – [discontinue (D/C)] Date- 01/05/2025 [10:49 a.m.] .[Divalproex sodium] Oral Tablet Delayed Release 250 MG . Give 2 tablet by mouth one time a day for seizure prevention -Order Date- 01/03/2025 [4:51 p.m.] -D/C Date- 01/05/2025 [10:49 a.m.] . The MAR indicated, Divalproex sodium was administered to Resident 1 on 1/4/25 at 9:00 a.m., 1/4/25 at 4:00 p.m. and 1/5/25 at 9:00 a.m. The DON stated, Divalproex sodium was administered to Resident 1 for seizure prevention on 1/4/25 at 9:00 a.m., 1/4/25 at 4:00 p.m. and 1/5/25 at 9:00 a.m. The DON stated, Resident 1 was not diagnosed with any seizure disorder. The DON stated, it was important to have the correct indication for use listed for Resident 1's order for Divalproex sodium because otherwise it was an unnecessary medication and there was not a valid reason to administer it to Resident 1. The DON stated possible side effects of Divalproex sodium included gastrointestinal distress, headaches, and liver complications. The DON stated, Divalproex sodium potentially altered Resident 1's behavior, mood and thought processes. During a phone interview on 1/16/25 at 4:32 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 1's Inter-Facility Transfer Report (IFTR) , was provided by the hospital to indicate which orders, including medications, Resident 1 should have continued upon admission to the facility. LVN 1 stated she administered Divalproex sodium on 1/5/25 at 9:00 a.m. to Resident 1 according to the medication orders. LVN 1 stated Resident 1's responsible party (RP) asked for Divalproex sodium to be discontinued. LVN 1 stated she called Resident 1's nurse practitioner (NP) and the NP ordered for the Divalproex sodium to be discontinued. During a phone interview on 1/17/25 at 3:00 p.m. with LVN 2, LVN 2 stated Divalproex sodium was prescribed to individuals as an anticonvulsant (to prevent seizures) medication and was also indicated to be used as a psychotropic medication. LVN 2 stated, it was important to administer the right medication with the appropriate indication according to the documented diagnoses of an individual. LVN 2 stated nurses should not administer an unnecessary medication like Divalproex sodium if Resident 1 did not have an appropriate diagnosis. During a phone interview on 1/17/25 at 3:45 p.m. with LVN 3, LVN 3 stated Resident 1's RP was worried during a visit with Resident 1 on 1/4/25 because Resident 1's mood was different than her usual self. LVN 3 stated Resident 1's RP was upset after finding out Resident 1 was given Divalproex sodium because Resident 1 had not taken Divalproex sodium for a long time. LVN 3 stated a medication should only be given to Resident 1 for an appropriate diagnosis and not unnecessarily because there was a potential for Resident 1 to experience side effects. 055869 Page 4 of 5 055869 01/15/2025 Valley Skilled Nursing Center 515 East Orangeburg Avenue Modesto, CA 95350

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's document titled, Psychotherapeutic [relating to the treatment of mental illness] Medication INFORMED CONSENT (PMIC) , undated, the PMIC indicated, .MISCELLANEOUS MEDICATIONS . Depakote . DOCUMENTATION NEEDED IN CHART .Diagnosis and target behavior indicated in the medication order . During a review of the Mayo Clinic website, https://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/description/drg-20072886, dated 8/31/24, the website indicated, .Divalproex sodium .is used to treat certain types of seizures .also used to treat the manic (extremely elevated and excited mood) phase of bipolar (mental illness that causes intense shifts in mood, energy levels and behavior) disorder .elderly patients are more likely to have unwanted effects . Liver problems may occur while .using this medicine, and some may be serious .Side Effects .Confusion .Delusions (a false belief or judgement about external reality, despite evidence, occurring in mental conditions) of persecution, mistrust, suspiciousness, or combativeness .False beliefs that cannot be changed by facts .False or unusual sense of well-being .Headaches .Nausea .Problems with memory or speech .Rapidly changing moods .Sleepiness or unusual drowsiness .Trouble thinking and planning .Uncontrolled chewing movements .Uncontrolled movements of the arms and legs .Vomiting . During a review of the facility's P&P titled, Psychotropic Medication Use , 7/22, the P&P indicated, .Residents will not receive medications that are not clinically indicated to treat a specific condition .A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior .Residents, families and/or the representative are involved in the medication management process. Psychotropic medication management includes: a. indications for use .Situations which may prompt an evaluation .of the resident include: a. admission .The evaluation may include .an evaluation of resident status (co-morbid conditions, symptoms, psychiatric diagnoses; etc.) . 055869 Page 5 of 5