Health inspection·July 2, 2024

F 0661 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Based on observation, interviews, and record reviews, the facility failed to ensure that one of two sampled residents, Resident 1, received an accurate reconciliation of medications (A process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that included the drug name, dosage, frequency, route, and indication for use for the purpose of preventing unintended changes or omissions at transition points in care) during her discharge, when Resident 1 received three (3) over the counter medications that were ordered for another resident, Resident 2. This failure had the potential to result in a medication error and could affect the safety and well-being of Resident 1, if she accidentally took the medications that were not ordered for her. Findings: On 7/2/2024, at 1:51 p.m., the facility's DON (Director of Nursing) provided a list of residents who were discharged in June 2024. The list included Resident 1, who was discharged on 6/7/24. During a concurrent observation and interview on 7/2/24, at 11:26 a.m., with Licensed Nurse A, she stated she remembered discharging a resident who called her pharmacy because she was discharged with medications that did not belong to her. Licensed Nurse A confirmed that it was Resident 1. Licensed Nurse A stated that she drove to Resident 1's home and took back the medications that were ordered for Resident 2. Licensed Nurse A stated that she still has the medications kept in a transparent plastic bag which she showed this surveyor. This surveyor took pictures of the contents of the bag with labels indicating that these three medications were for Resident 2. Licensed Nurse A stated that she was taking responsibility for the incident. Licensed Nurse A stated that Resident 1 could be at risk if she was allergic to any of the three medications that were sent home with her during her discharge. Licensed Nurse A stated that she did not document the incident, but stated she might have verbally notified the DON. Licensed Nurse A stated that the over-the-counter medications were all sealed and unopened. This surveyor verified that the medications were unopened during inspection. A review of Resident 1's Progress Notes, dated 6/7/24, at 9:10 a.m., authored by Licensed Nurse A, indicated, Resident 1 is schedule to discharge home today as per MD (Doctor's) orders. All discharge instructions including medication regimen review with resident (Resident 1) who verbalized understanding .Resident 1 left the facility at this time .all belongings taken at this time. During an interview on 7/2/24, at 12:30 p.m., with the DON, she stated that it was her expectation that medications should be discharged to the right resident. The DON stated that if the resident was not alert as Resident 1, there would be a potential for harm if that resident accidentally took the medications. The DON stated that it was the facility's responsibility, not the pharmacy, to double (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: 055919 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 055919 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Apple Valley Post-Acute Rehab 1035 Gravenstein Hwy South Sebastopol, CA 95472 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)