Health inspection·July 25, 2023

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 and record review, for one of three sampled residents (Resident 1), the facility failed to ensure Resident 1 was administered buspirone (treats anxiety) with adequate monitoring of adverse effects from the medication. Residents Affected - Few This failure had the potential to result in delayed management of adverse effects and unnecessary use of medication. Findings: Review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included generalized anxiety disorder (excessive and overwhelming worry about ordinary issues like work, money and family) and anoxic brain damage (brain is deprived of oxygen, symptoms include changes in sleep pattern, trouble speaking and swallowing). Review of Resident 1's Order Summary Report for September 2022 indicated an order for Resident 1 to receive buspirone 5 milligrams via PEG (percutaneous endoscopic gastrostomy, a flexible tube is placed through the abdominal wall into the stomach to receive nutrition and/or medication) two times daily for agitation, restlessness and falling tendency. During a concurrent interview and review of Medication Administration Record (MAR) for August 2022 with Assistant Director of Nursing (ADON) on 7/25/23 at 11:59 a.m., ADON stated, Resident 1's MAR indicated monitoring for antipsychotic (medication that treats psychosis, a severe mental illness) adverse effects was done. ADON stated, Resident 1 was given buspirone, which was an anti anxiety and not an antipsychotic, and had different adverse effects. Review of Resident 1's Medication Administration Record (MAR) for September 2022 indicated Resident 1 was monitored for the presence of tardive dyskinesia (facial tongue movement), cognitive impairment (decreased mental status), akathisia (inability to sit still), parkinsonism (tremors, rigidity, drooling). According to Dailymed, a nationally-recognized publication of the National Institute of Health in the U.S. National Library of Medicine and includes references to drug information submitted to the Food and Drug Administration, buspirone adverse events include; dizziness, insomnia, nervousness, drowsiness, lightheadedness, nausea, headache and fatigue. Review of the facility's policy and procedure titled Psychotropic Medication Management last revised 10/24/17 indicated, Medication effects will be monitored and documented on the medication (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055885 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 055885 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Country Drive Post Acute 2500 Country Drive Fremont, CA 94536 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)