Health inspection·September 4, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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, the facility failed to ensure licensed nurses administered medications in accordance with professional standards of practice for one of three sampled residents (Resident 1), when Resident 1 received medications that were not prescribed for her on 8/20/24. Residents Affected - Few This failure resulted in Resident 1 receiving medication not prescribed for her which had the potential to place Resident 1 at risk for adverse drug effects (an injury resulting from medical intervention related to a drug that includes medication errors). Findings: During a review of Resident 1's admission Record (AR) (document containing resident demographic information and medical diagnosis), dated 09/4/24, the AR indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnosis included but are not limited to .TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS (chronic condition that affects the way the body processes blood sugar) .HYPO-OSMOLALITY AND HYPONATREMIA (having low levels of electrolytes (including sodium), proteins and nutrients) . During a review of Resident 1's admission MDS assessment, dated 8/26/24, the admission MDS assessment indicated, Resident 1's Brief Interview for Mental Status (BIMS -an evaluation of attention, orientation, and memory recall) score of 13 (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, 13-15 no cognitive impairment), indicating Resident 1 had no cognitive impairment. During a concurrent interview and record review on 9/4/24 at 4:00 p.m., with Licensed Vocational Nurse LVN) 1, Residents 1 ' s Medication Order Summary Report dated 9/4/24 was reviewed. LVN 1 stated Resident 1 ' s Physician orders did not include pantoprazole 40 mg 1 tablet, carvedilol 6.25mg 1 tablet, potassium phosphate 500 mg 0.5 tablet, amlodipine 5 mg 1 tablet, memantine 5 mg 1 tablet, pioglitazone 30 mg 1 tablet. LVN 1 stated she failed to verify the right patient prior to administering pantoprazole 40 mg 1 tablet , carvedilol 6.25mg 1 tablet, potassium phosphate 500 mg 0.5 tablet, amlodipine 5 mg 1 tablet, memantine 5 mg 1 tablet, pioglitazone 30 mg 1 tablet. LVN 1 stated she assumed it was the right person by the picture provided in the medication administration software. LVN 1 stated she did not follow doctor ' s directions for medication administration and did not follow facility policies. LVN 1 stated it is the responsibility of the nurse to provide medications per the physician order and verify the correct patient during medication administration. LVN 1 stated she was taught to verify the correct patient prior to medication dosage administration but she did not follow her training and provided the medication without confirmation. LVN 1 stated it is the expectation of all nursing staff to follow doctor ' s orders, and to ensure the correct resident is given the correct medication. LVN 1 stated giving a resident the wrong medication can put resident at risk for (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: 055955 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 055955 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727 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)