Health inspection·March 14, 2019

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 observation, interview, and record review, a physician's order to assess and document pain level each shift was not followed for one of four residents reviewed for pain (204). Residents Affected - Few This failure caused the potential for Resident 204 to suffer unnecessary pain. Findings: Resident 204 was admitted to the facility on [DATE] with diagnoses that included chronic pain, per the facility's Record of Admission. The clinical record for Resident 204 was reviewed on 3/11/19. The Physician's Order Form indicated an admission order of tramadol (Ultram), 50 mg, PO, PRN, every six hours for moderate pain. The Physician's Order Form indicated an admission order of Pain Assessment QS (each shift), 0-10 pain scale (a pain scale used by physician's to indicate pain level with 0 being no pain and 10 being the most possible pain). The MAR indicated on 3/7/19 and 3/8/19 pain was not assessed or documented on either the 7 A.M. - 3 P.M. shift or the 3 P.M. - 11 P.M. shift. The MDS, dated [DATE], section C, Cognitive Patterns, showed Resident 204 had a BIMS of 14 (12-15 scores indicate mentally intact). On 3/11/19 at 11:21 A.M., an interview was conducted with Resident 204. Resident 204 stated he was in pain. He stated, I don't think they are giving me the tramadol I'm supposed to get. I've been complaining of pain. On 3/12/19 at 9:20 A.M., the ADON was observed conducting an interview with Resident 204. The ADON asked Resident 204 where he hurt and he stated his right hip. The ADON pressed Resident 204's right hip and he groaned and jumped in pain. Resident 204 stated he was in 8/10 pain most of the time since he had been here and thought something was wrong with his artificial hip socket. The ADON confirmed Resident 204 appeared to be in pain. On 3/14/19 at 10:58 A.M., an interview was conducted with the DON. The DON confirmed pain was not assessed on four different shifts for Resident 204 since he had been in the facility. The DON stated Page 1 of 18 055964 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0658 Resident 204 may have had untreated pain during those shifts when pain was not assessed. Level of Harm - Minimal harm or potential for actual harm The facility policy titled Pain Assessment and Management, revised April 2018, indicated, .Assess the resident's pain and consequences of pain at least each shift .upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident's medical record . Residents Affected - Few 055964 Page 2 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0697 Provide safe, appropriate pain management for a resident who requires such services. 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 monitor and manage pain in one of four resident's reviewed for pain (204) in accordance with the comprehensive assessment and care plan. Residents Affected - Few This failure had the potential to cause Resident 204 to endure unnecessary pain. Findings: Resident 204 was admitted to the facility on [DATE] with diagnoses that included chronic pain, per the facility's Record of Admission. The clinical record for Resident 204 was reviewed on 3/11/19. The Physician's Order Form indicated an admission order of tramadol (Ultram), 50 mg, PO, PRN, every six hours for moderate pain. The Physician's Order Form indicated an admission order of Pain Assessment QS (each shift), 0-10 pain scale (a pain scale used by physician's to indicate pain level with 0 being no pain and 10 being the most possible pain). The MAR indicated pain was not assessed on 3/7/19 or 3/8/19 on either the 7 A.M. - 3 P.M. shift or the 3 P.M. - 11 P.M. shift. The MAR indicated tramadol was administered on 3/7/19 and 3/9/19. The MAR did not indicate when tramadol was given on 3/7/19, or the pain level pre or post administration. The MAR indicated tramadol was administered on 3/9/19 at 1:40 P.M., but did not indicate Resident 204's pre or post pain level. The MDS, dated [DATE], section C, Cognitive Patterns, showed Resident 204 had a BIMS of 14 (12-15 indicated mentally intact). The Pain Assessment conducted for Resident 204 on admission to the facility on 3/6/19 indicated Resident 204 stated he had aching pain, and that mobility and movement increased the pain. Resident 204's Care Plan, titled Pain, dated 3/6/19, indicated Resident 204 was At risk for pain due to diagnosis .chronic pain . Interventions included .Assess pain level Q (each) shift .and chart it .Medication as ordered . The Physician Controlled Medication Order Form, undated, indicated tramadol 50 mg, by mouth one tab, PRN Q6H (every six hours) for moderate pain was ordered by the physician for Resident 204 to be delivered by the pharmacy. The quantity prescribed line was left blank. On 3/11/19 at 11:21 A.M., an interview was conducted with Resident 204. Resident 204 stated he was in pain. He stated, I don't think they are giving me the tramadol I'm supposed to get. I've been complaining of pain. On 3/11/19 at 4:40 P.M., a concurrent interview and record review was conducted with the ADON. The ADON stated the cubex records indicated tramadol was taken out of the cubex on 3/7/19 and 3/9/19. 055964 Page 3 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few The ADON stated she did not know why the tramadol ordered by the physician for Resident 204 had not arrived at the facility, since it had been ordered on 3/6/19. On 3/12/19 at 7:15 A.M., a concurrent interview and observation was conducted with Resident 204. Resident 204 stated he did not receive any pain medication last night even though he was in pain. Resident 204 stated he was in 7/10 pain right now, touched his right hip and grimaced in pain. Resident 204 stated, I don't know why they're not giving me my tramadol. On 3/12/19 at 7:31 A.M., an interview was conducted with the DON. The DON stated the tramadol for Resident 204 came in from the pharmacy last night at 6 P.M. On 3/12/19 at 9:20 A.M., the ADON was observed conducting an interview with Resident 204. The ADON asked Resident 204 where he hurt and he stated his right hip. The ADON pressed her fingers into Resident 204's right hip and he groaned and jumped in pain. Resident 204 stated he was in 8/10 pain most of the time since he had been here and thought something was wrong with his artificial hip socket. The ADON confirmed Resident 204 appeared to be in pain. On 3/13/19 at 11:50 A.M., a telephone interview was conducted with Pharm A. Pharm A stated they had received the order from the facility on 3/6/19 for tramadol but the order didn't have the quantity of medication ordered so they could not fill it. Pharm A stated the facility had not reached out to them about this order. On 3/13/19 at 1:35 P.M., an interview was conducted with the DON. The DON confirmed the facility did not contact the pharmacy about the missing tramadol. The DON acknowledged there were issues with the pharmacy ordering procedures and the facility did not know the tramadol had not arrived. On 3/14/19 at 10:58 A.M., an interview was conducted with the DON. The DON acknowledged pain had not been assessed each shift, or correctly documented when pain medication was given, nor was pre and post pain documented for Resident 204. The DON stated Resident 204 may have had pain untreated during his stay at the facility. The facility policy titled Pain Assessment and Management, revised April 2018, indicated, .Implement the medication regimen as ordered, carefully documenting the results of the interventions .monitoring for the effectiveness of interventions . 055964 Page 4 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. 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 fluid restriction was implemented for one of two residents (9) reviewed for dialysis. Residents Affected - Few This failure had the potential to result in fluid overload for this resident. Findings: Resident 9 was admitted to the facility on [DATE] with diagnoses that included end-stage renal disease (kidneys no longer function effectively) and dependence on kidney dialysis (an artificial means of cleansing the blood), per the facility's Record of Admission. Findings: On 03/11/19 at 10:24 A.M., an observation was made in Resident 9's room. A full pitcher of water (1000 cc) and a big gulp (a beverage that is 30 ounces=900 cc) were on the bedside table. In addition, Resident 9's breakfast tray contained a carton of milk (240 cc's). A review of Resident 9's medical record indicated a physician's order, dated, 8/9/18, .1000 cc fluid restriction . A review of Resident 9's nursing care plan, dated 8/5/18, titled, Hemodialysis, indicated, .potential for complications of fluid overload . interventions . fluid restriction as ordered 1000 cc . An interview was conducted with RNS 11 on 3/13/19 at 11:22 A.M. RNS 11 stated, The water pitcher and big gulp shouldn't be there, it can lead to fluid overload. A concurrent interview and record review was conducted with RNS 11 on 3/13/19 at 11:24 A.M. RNS 11 reviewed the Intake and Output Fluid log (I & O - documentation of fluid intake) for Resident 9. The I & O log indicated the following: 11/27/18: total fluids 1240 cc 11/30/18: total fluids 1140 cc 12/1/18: total fluids 1240 cc 3/3/19: total fluids 2020 cc RNS 11 stated, There are several days over 1000 cc; it can cause fluid overload. On 3/14/19 at 8:59 A.M., an interview was conducted with the DON. The DON stated, The fluid restriction is important because this resident is on dialysis and it could result in fluid overload. A review of the facility's policy, dated 6/03, titled, Fluid Restriction, indicated, Policy: Patients requiring a controlled amount of fluid intake (fluid restriction) are provided the correct amount of daily fluid by designated staff as indicated in the fluid restriction medical order. 055964 Page 5 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Resident 86's clinical record was reviewed on 3/14/19. Residents Affected - Some Resident 86's medication usage record for oxycodone/acetaminophen 5/325 mg (a schedule II medication) was reviewed. According to the dispensing records, 60 tablets were removed from the inventory. According to the administration records, 40 tablets were administered to Resident 86. Therefore, 20 tablets were not accounted for. 2b. Resident 27's clinical record was reviewed on 3/14/19. Resident 27's medication usage record for hydrocodone/acetaminophen 5/325 mg (a schedule II medication) was reviewed. According to the dispensing records, 23 tablets were removed from the inventory. According to the administration records for the same timeframe, 7 tablets were administered to Resident 27. Therefore, 16 tablets were not accounted for. 2c. Resident 70's clinical record was reviewed on 3/14/19. Resident 70's medication usage record for oxycodone 10 mg (a schedule II medication) was reviewed. According to the dispensing records, 52 tablets were removed from the inventory. According to the administration records for the same timeframe, 20 tablets were administered to Resident 70. Therefore, 32 tablets were not accounted for. The DON and ADON were interviewed on 03/14/19 at 2:02 P.M. They stated medication administration should have been documented in the clinical record. According to the facility's policy, Charting and Documentation, dated 4/18, . medications administered . must be documented in the resident's clinical records. Based on observation, interview, and record review, the facility failed to ensure: 1. Accurate and timely pharmaceutical services for delivery of a physician ordered pain medication for one of four residents reviewed for pain (Resident 204), and, 055964 Page 6 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. A system of records that enabled accurate reconciliation and accountability of schedule medications was established, when 68 tablets of schedule II medications were not accounted for, for 3 randomly sampled residents (68, 27, and 70). The Drug Enforcement Agency (DEA) classifies medications with abuse potentials into schedules, from schedule II to schedule V. Schedule II has the highest potential for abuse, and schedule V has the lowest potential for abuse. These failures had the potential to cause Resident 204 to endure unnecessary pain, and the facility to not be aware if controlled drugs were being diverted (misused or abused). Findings: 1. Resident 204 was admitted to the facility on [DATE] with diagnoses that included chronic pain, per the facility's Record of Admission. The clinical record for Resident 204 was reviewed on 3/11/19. The Physician's Order Form indicated an admission order of tramadol (Ultram), 50 mg, PO, PRN, every six hours for moderate pain. The MAR indicated tramadol was administered on 3/7/19 and 3/9/19. The MAR did not indicate when tramadol was given on 3/7/19, or where it was obtained. The MAR indicated tramadol was administered on 3/9/19 and was obtained from the cubex (emergency medication supply). Resident 204's Care Plan, titled Pain, dated 3/6/19, indicated Resident 204 was At risk for pain due to diagnosis of .chronic pain . Interventions included .Assess pain level Q (each) shift using 0-10 scale (a pain scale used by physician's to indicate pain level with 0 being no pain and 10 being the most possible pain) before medicating and chart it .Medication as ordered . The Physician Controlled Medication Order Form, undated, indicated tramadol 50 mg, by mouth one tab, PRN Q6H (every six hours) for moderate pain was ordered by the physician for Resident 204 to be delivered by the pharmacy. The quantity prescribed line was left blank. On 3/11/19 at 11:21 A.M., an interview was conducted with Resident 204. Resident 204 stated he was in pain. He stated, I don't think they are giving me the tramadol I'm supposed to get. I've been complaining of pain. On 3/11/19 at 4:40 P.M., a concurrent interview and record review was conducted with the ADON. The ADON stated the cubex records indicated tramadol was taken out of cubex on 3/7/19 and 3/9/19. The ADON stated she did not know why the physician ordered tramadol for Resident 204 had not arrived at the facility, since it was ordered on 3/6/19. On 3/12/19 at 7:31 A.M., an interview was conducted with the DON. The DON stated the tramadol for Resident 204 came in from pharmacy last night at 6 P.M. On 3/13/19 at 11:50 A.M., a call was made to the pharmacy and an interview with Pharm A was conducted. Pharm A stated they had received the order from the facility on the 3/6/19 for tramadol but the order didn't have the quantity of medication ordered so they could not fill it. Pharm A stated the 055964 Page 7 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0755 facility had not reached out to them about this order. Level of Harm - Minimal harm or potential for actual harm On 3/13/19 at 1:35 P.M., an interview was conducted with the DON. The DON confirmed the facility did not contact the pharmacy about the missing tramadol. The DON acknowledged there were issues with the pharmacy ordering procedures and the facility did not know the tramadol had not arrived. Residents Affected - Some The facility policy titled Pain Assessment and Management, revised April 2018, indicates, .Implement the medication regimen as ordered . 055964 Page 8 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three residents reviewed for psychotropic medications (21, 90 and 97) received: 1. Clinical approval for a PRN psychotropic medication (lorazepam - a medication affecting mental state) to be used beyond fourteen days, and 2. Each resident's drug regimen was free from unnecessary drugs. Resident 21 was prescribed and administered Nuplazid, an antipsychotic medication (treatment of psychosis - thought and emotions are so impaired that contact is lost with external reality), with inconsistent indication for use and lacked documented non-pharmacological intervention, and clinical justification to support the long term use. Resident 90 was ordered and administered Cymbalta, an antidepressant (medication to treat mood disorder), for nerve pain while no monitoring of side effects of the medication was performed or documented. These failures had the potential for medication interactions, adverse effects and risks associated with the use of these medications a higher dose and/or longer than needed. Findings: 1. Resident 97 was readmitted to the facility on [DATE] with diagnoses that included unspecified psychosis and schizoaffective disorder (a combination of visual and/or auditory hallucinations with mood swings), per the facility's Record of Admission. The clinical record for Resident 97 was reviewed on 3/13/19. The Physician's admission Orders, dated 2/20/19, indicated an order for lorazepam, 1 mg. Give 1 tab by mouth BID, PRN for anxiety. The MAR for Resident 97 indicated lorazepam was ordered and administered from 2/20/19 through 3/13/19, a period of 22 days. A Physician's Telephone Order form indicated an order was written on 3/6/19 to Continue Ativan (lorazepam), 1 mg, BID for anxiety for 14 more days. Another order on the same form indicated, Psych consult .for med review - possible GDR (gradual dose reduction) of Ativan. On 3/14/19 at 11:02 A.M., a concurrent interview and record review was conducted with the DON. The DON confirmed lorazepam for Resident 97 was a PRN order, and it should not have been administered for longer than 14 days without a clinical reevaluation. The DON stated the psychiatrist was scheduled to review the medication on the 20th of March, 29 days from when it was first ordered. The DON stated Resident 97 may not need the medication, and may become dependent on it unnecessarily. The facility policy titled Psychoactive Medications, dated 10/2017, did not provide guidance for the use of a PRN psychotropic medication beyond 14 days without clinical justification. 055964 Page 9 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0758 Level of Harm - Minimal harm or potential for actual harm 2a. On 3/14/19, Resident 21's medical record was reviewed. Resident 21 was admitted on [DATE] with diagnoses including unspecified dementia (decrease in mental activity that affects daily life) without behavioral disturbance, unspecified psychosis (mental condition that makes it hard to tell what is reality and what is not reality) not due to a substance or known physiological condition, and pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder). Residents Affected - Few The medications prescribed for Resident 21 included: On 9/19/14 a physician's order for Resident 21 indicated, Nuedexta (dextromethorphan and quinidine) 20-10mg capsule, take 1 capsule by mouth every twelve hours for pseudobulbar affect/depression, and monitor for side effects and episodes of depression every shift as evidenced by inappropriate crying without a reason. On 7/19/17 a physician's order for Resident 21 indicated, Nuplazid 34 mg capsule, take 1 capsule by mouth daily, monitor for side effects every shift, and for episodes of psychosis every shift as evidenced by hitting and kicking staff. A review of Resident 21's MAR indicated that Nuplazid was administered from 3/1/18 to 3/14/19. The monitoring portion of the MAR indicated no behavioral episodes were charted from 3/1/18 to 3/14/19. A review of Resident 21's care plan for Nuplazid, dated 7/13/17, indicated Has episodes of: Psychosis; Exhibit by: Hitting/Kicking staff; Related to .Dementia. According to Lexicomp, a nationally recognized drug reference, Nuplazid is an antipsychotic used for the treatment of hallucinations (seeing or hearing things that are not real) and delusions (false beliefs)associated with Parkinson (uncontrolled movement) disease psychosis. Nuplazid contains the following US Boxed Warning: Elderly patients with dementia-related psychosis treated with antipsychotics are at an increased risk of death .[Nuplazid] is not approved for the treatment of dementia-related psychosis unrelated to the hallucinations and delusions associated with Parkinson disease psychosis. A review of Resident 21's MAR indicated Nuedexta was administered to Resident 21 from 3/1/18 to 3/14/19. The monitoring portion of the MAR indicated no behavioral episodes were charted from 3/1/18 to 3/14/19. According to Lexicomp, a nationally recognized drug reference, Nuedexta is used for Pseudobulbar affect (PBA). In addition, .Special populations: Dementia: Has not shown to be safe or effective in other types of commonly occurring emotional labilities (eg, neurological disease or injury . Other warnings/precautions: Appropriate use: Periodically reassess the need for treatment, spontaneous improvement of PBA may occur On 3/14/19 at 1:10 P.M., during a concurrent observation and interview, LN 33 stated, she had not seen Resident 21 crying and could not picture Resident 21 hitting or kicking staff. LN 33 stated, she could not find any documentation for Resident 21 hitting and kicking staff in the chart. LN 33 also stated, she had not seen Resident 21 expressing sadness. LN 33 stated, Resident 21 seemed jolly and could assess if he was depressed by his facial expression. A form titled, Inform Consent for Alternate Behavioral Drug, signed by a LN on 9/19/14, indicated 055964 Page 10 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few .non-drug interventions tried prior to medication . Encourage to verbalize feelings/concerns unsuccessful . Attempts to redirect . unsuccessful . Assess for pain . unsuccessful. A form titled, Inform Consent for . Antipsychotic, signed by a LN on 7/13/17, indicated .non-drug interventions tried prior to medication . Encourage to verbalize feelings/concerns unsuccessful . Attempts to redirect . unsuccessful . Assess for pain . unsuccessful. On 3/14/19 at 3:06 P.M., during a concurrent observation and interview, the DON stated, there was no record of non-drug intervention attempts prior to initiation of Nuedexta and Nuplazid in Resident 21's medical records. A review of the facility's consultant pharmacist monthly regimen review for Resident 21 titled, Note to Attending Physician/Prescriber, dated 7/3/18, indicated, Resident has been on the same dose of Nuplazid 34 mg . since 7/17. GDR is due if medically warranted . A GDR must be attempted on psychoactive medications, unless clinically contraindicated. Since I could not find documentation that a . GDR . is contraindicated, please check one of the following below to keep the facility in compliance with . unnecessary medications in the elderly A review of practitioner monthly visit for Resident 21, dated 7/26/18, indicated, Psychosis: Continue Nuplazid. Psych to follow . Monitor for medication effectiveness and side effects. A review of Resident 21's clinical record indicated, no behavioral episodes were charted for 11/18. A review of the facility's consultant pharmacist monthly regimen review for Resident 21 titled, Note to Attending Physician/Prescriber, dated 3/1/19, indicated, Resident has been on Nuedexta since 9/14. Per manufacturer recommendations, there should be periodical assessments needed during treatment. The facility's policy and procedure titled, Consultant Pharmacist Reports Medication Regimen Review, dated 12/16 indicated, Resident specific irregularities and/or clinical significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, and/or prescriber as appropriate . Recommendations are acted upon and documented by the facility staff and or the prescriber . Physician accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . If there is a potential for serious harm and the attending physician does not concur, or the attending physician refuses to document an explanation for disagreeing, the director of nursing or designee contacts the medical director On 3/14/19 at 5:31 P.M., during an interview, the ADON stated, the consultant pharmacist recommendation dated 7/3/18 and 3/1/19 were not in Resident 21's medical chart and had to be printed out. The ADON stated, the prescriber monthly visit notes were the only records in response to consultant pharmacist recommendations. The ADON acknowledged, the prescriber monthly visit notes did not provide a clinical justification for continued dosage and use of Nuplazid and Nuedexta. Resident 21's clinical record did not show there were any attempts to reduce the dose of Nuplazid and Nuedexta gradually since the initiation of the therapy from 3/2018 to 3/2019, and there was no documented clinical contraindication indicating any attempts to gradually reduce Resident 21's Nuplazid and Nuedexta would be inappropriate. 055964 Page 11 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0758 Level of Harm - Minimal harm or potential for actual harm 2b. On 3/14/19, Resident 90's medical record was reviewed. The resident was readmitted on [DATE], with diagnoses including type 2 diabetes (high blood sugar) with diabetic neuropathy (nerve pain associated with high blood sugar), per the facility's Record of Admission. The medications prescribed for Resident 90 included, Cymbalta 60 mg by mouth daily for nerve pain. Residents Affected - Few A review of Resident 90's MAR indicated, Cymbalta was administered to Resident 90 from 2/19/19 to 3/14/19. On 3/14/19 at 11:40 A.M., during an interview, LN 34 stated, Resident 90 did not have a care plan because Cymbalta was used for nerve pain, not depression. On 3/14/19 at 1:40 P.M., during an interview, LN 34 stated, she assessed Resident 90 for pain and documented side effects on the skilled nursing progress notes. LN 34 stated, if there were no side effects, she would make notation on the skilled nursing progress notes. Upon review of Resident 90's skilled nursing progress notes, LN 34 acknowledged, there was no monitoring of side effects for Cymbalta documented in skilled nursing progress notes dated 2/19/19 to 3/13/19. LN 34 also acknowledged, there was no monitoring of side effects for Cymbalta in Resident 90's MAR. According to Lexicomp, a recognized drug information provider for health professionals indicated the following adverse effects related to the use of Cymbalta, .severe skin reactions . unexplained bone pain, point tenderness, swelling, or bruising . Discontinue therapy with the presentation of [severe liver diseases] The facility's policy and procedures titled, Administering Medications, dated 6/16, indicated, .If a resident experiences potential adverse consequences or is suspected of being associated with adverse consequences, the licensed nurse shall contact the resident's physician . 055964 Page 12 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure the medication error rate was below 5 percent. The medication error rate was 7.69 percent. Two medication errors were observed, from a total of 26 opportunities, during the medication administration process for two randomly observed residents (44, 303). Residents Affected - Few As a result, the facility could not ensure medications were correctly administered to the residents. Findings: 1. On 3/12/19 at 8:34 A.M., an observation of medication administration with LN 22 was conducted. LN 22 prepared Resident 44's medications from the North Hall 1 medication cart. LN 22 administered medications to Resident 44, including loratadine (a medication to treat allergies). On 3/13/19 at 3:56 P.M. a record review of Resident 44's physician orders were conducted. There was no physician order for loratadine. A physician order, dated 3/4/19, indicated cetirizine (allergy medication) to be given daily for allergies. On 3/13/19 at 3:58 P.M., a concurrent interview and record review with RNS 11 was conducted. RNS 11 stated, Resident 44's MAR indicated to administer cetirizine every day, not loratadine. On 3/13/19 at 4:03 P.M., an observation of the North Hall 1 medication cart with RNS 23, was conducted. RNS 23 was able to locate the bottle of loratadine in the medication cart, but could not find a bottle of cetirizine. RNS 23 stated, cetirizine was not stocked in the medication cart. On 3/14/19 at 5:24 P.M., an interview with the DON was conducted. The DON stated, LNs were expected to administer the correct medication to each resident. The DON further stated, if the wrong medication was given, LNs were expected to notify the physician and to monitor for any adverse effects and report them to the physician. 2. On 3/13/19 at 8:35 A.M., during a medication administration observation, LN 31 was observed preparing and administering medications to Resident 303 that included, Senna 5 mL. On 3/13/19 at 3:36 P.M., during a concurrent record review and interview, LN 31 stated, the physician's order was, Senna . give 10 mL LN 31 acknowledged, she had given Resident 303 the incorrect Senna dose. On 3/14/19 at 8:27 A.M., during an interview, the DON stated, LNs should have administered the correct dose. A review of the facility's policy and procedure, titled, Administering Medications, dated 6/16, indicated, . Medications must be administered in accordance with the orders . The licensed nurse must check to verify . right medication, right dosage . before giving the medication . 055964 Page 13 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure one of two emergency kits (e-kit, emergency medications to be used in the case of an emergency) had a list of its contents, with expiration dates, readily available. This failure had the potential for the delay in locating and delivering necessary medications to residents in the event of an emergency. Findings: On 3/13/19 at 10:14 A.M., a concurrent observation and interview, with the DON and the ADON, was conducted. The medication storage contained an e-kit, labeled, South e-kit. The South e-kit did not have a list of its contents visibly placed along its outside. The DON, and the ADON, were unable to locate a list of the contents stored within the South e-kit. On 3/14/19 at 2:43 P.M. an interview with the DON was conducted. The DON stated, the facility did not have a list of the South e-kit's contents and expiration dates, according to their policy. The DON further stated, they should have had a list of the South e-kit's contents with expiration dates available. A review of the facility's policy and procedure titled, Emergency Pharmacy Service and Emergency Kits, dated 12/1/16, indicated, . F. The emergency supply is maintained . along with a list of supply contents and expiration dates . 055964 Page 14 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure fresh produce was labeled with a use-by date. Residents Affected - Some This failure had the potential to expose a vulnerable population to food-borne illness. Findings: On 3/11/19 at 8:21 A.M., an observation was conducted during the initial tour of the kitchen with the CDM 1 and CDM 2. Three boxes of fresh produce (tomatoes, potatoes, and apples) were stored in the refrigerator; there was no use-by date posted on any of the boxes. An interview was conducted on 3/11/19 at 8:23 A.M. with CDM 1. CDM 1 stated, Staff just look at it (the produce) and see if it looks ok. An interview was conducted on 3/13/19 at 10:50 A.M. with CDM 1. CDM 1 stated, Our policy says to go by the vendors recommendations; we don't have that (posted). An interview was conducted with the DON on 3/14/19 at 11:34 A.M. The DON stated, Staff should have the vendor's guidelines posted so they know how long the produce is good. A review of the facility's guidelines, dated 1/30/2012, titled, Food Product Shelf-Life Guideline, indicated, .Fresh Produce, check with your produce vendor for guidelines 055964 Page 15 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0880 Provide and implement an infection prevention and control program. 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 implement the infection control program when: Residents Affected - Some 1. A nurse practitioner did not implement hand hygiene during a dressing change. 2. A staff member did not don (put on articles of clothing) appropriate personal protective equipment before entering an isolation room. 3. A staff member did not sanitize (to clean and make free of disease causing elements) a blood pressure cuff after resident use. 4. A staff did not follow safe hand washing/hand hygiene practices while handling a gastronomy tube (GTtube surgically inserted into stomach through abdominal wall to deliver food and medications) bag and during the administration of medication for one resident observed (303). These failures had the potential to transmit communicable diseases to other residents. Findings: 1. Resident 9 was admitted to the facility with diagnoses that included a pressure ulcer of the right heel, per the facility's Record of Admission. On 3/14/19 at 9:19 A.M., an observation was made of Resident 9's dressing change. The NP donned gloves but did not wash his hands first. The NP completed the dressing change, removed his gloves and used hand sanitizer (an alcohol based gel), with no hand washing. An interview was conducted with the NP on 3/14/19 at 9:30 A.M. The NP stated, I always use the alcohol, but I should wash my hands. An interview was conducted with the DON on 3/14/19 at 11:59 A.M. The DON stated, The NP should have washed his hands; it is an infection control problem. A review of the facility's policy titled, Hand Washing-Hand Hygiene, dated 8/2017, indicated, . 2. Personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. When indicated, employees must wash hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water 2. Resident 70 was re-admitted to the facility on [DATE], per the facility's Record of Admission. On 3/11/19 at 4:21 P.M., an observation of Resident 70's room, was conducted. A red hexagon (a six-sided shape) sign indicated, Stop. Visitors: please see nurse before entering room. A plastic bin placed to the right of the doorway, contained gowns, gloves and masks. There were three beds in the room, indicating three residents lived in the room. 055964 Page 16 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0880 Level of Harm - Minimal harm or potential for actual harm On 3/11/19 at 4:31 P.M., an observation of CNA 21 was conducted. The call light turned on above Resident 70's room. CNA 21 entered Resident 70's room without donning PPE, and asked Resident 70 what he needed. Resident 70 stated he wanted his oxygen on. CNA 21 exited the room to ask the nurse which resident in Resident 70's room was in contact precautions. CNA 21 returned and was observed donning a mask and gloves. CNA 21 entered the room and assisted Resident 70 with his oxygen. Residents Affected - Some On 3/11/19 at 4:31 P.M. an interview with CNA 21 was conducted. CNA 21 stated, Resident 70 was on contact precautions for an infection in the urine. CNA 21 stated, she should have worn a gown when assisting Resident 70. On 3/11/19 at 4:46 P.M., an observation and interview with CNA 22, was conducted. CNA 22 stated, a red hexagon sign meant isolation, and staff were required to wear gowns, masks and gloves, before entering. CNA 22 further stated, if a resident in contact precautions, needed help with his oxygen, she would wear a gown, gloves and a mask. CNA 22 stated, it was very important not to touch the patient without wearing the equipment, for infection control and safety of the residents. On 3/14/19 at 11:39 A.M., an interview with RNS 11 was conducted. RNS 11 stated, all nursing staff were expected to put on protective equipment before entering the room, when a red hexagon sign was on the door. RNS 11 stated, if a staff member was assisting the resident with their oxygen, or talking to the resident, staff must wear gowns, regardless. On 3/14/19 at 2:25 P.M., an interview with the DON was conducted. The DON stated, staff were expected to wear the appropriate PPE, when assisting residents with their oxygen. A review of the facility's policy and procedure titled, Contact Precautions, dated 2/18, indicated, . 2. Staff shall wear a gown and gloves for all interactions that may involve contact with the patient or the resident's environment. 3. PPE should be donned upon entering the room . when staff will have contact with the patient or potentially affected surfaces in the resident's room 3. Resident 44 was re-admitted to the facility on [DATE], per the facility's Record of Admission. On 3/12/19 at 8:34 A.M., an observation of LN 22 performing a medication pass for Resident 44, was conducted. LN 22 obtained Resident 44's BP using a portable wrist BP cuff. LN 22 placed the wrist BP cuff on the medication cart, and proceeded with preparing Resident 44's medications. LN 22 was not observed to sanitize the wrist BP cuff during the medication preparation. On 3/12/19 at 9:04 A.M. an interview with LN 22 was conducted. LN 22 stated, BP cuffs were usually cleaned right after resident use, with bleach wipes. LN 22 stated, she did not clean the BP cuff after use with Resident 44. On 3/14/19 at 2:30 P.M., an interview with the DON was conducted. The DON stated, LNs were expected to sanitize wrist BP cuffs before and after each use with a resident, upon exiting the resident's room. The DON stated the LN should have sanitized the wrist BP cuff. A review of the facility's policy and procedure titled, Cleaning and Disinfection of Resident Care items and Equipment, dated 1/12/17, indicated, . Non-critical resident-care items include . blood pressure cuffs . Reusable resident care equipment will be decontaminated and/or sterilized between residents. low-level disinfectants for non-critical items include . sodium hypochlorite (bleach) 055964 Page 17 of 18 055964 03/14/2019 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4. On 3/13/19 at 8:35 A.M., during a medication administration observation, LN 31 was observed handling medication bottles, crushing each medication, and handling the medication cart. LN 31 then entered Resident 303's room and proceeded to put on gloves without sanitizing her hands, administering each medication via GT. On 3/13/19 at 2:40 P.M., LN 32 was observed entering Resident 303's room. Upon entry, LN 32 proceeded to handle Resident 303's water bag without sanitizing her hands. After handling Resident 303's water bag, LN 32 left the room without sanitizing her hands. On 3/13/19 at 2:47 P.M., during an interview, LN 32 stated she should have sanitized her hands before and after entering Resident 303's room. On 3/14/19 at 8:27 A.M., during an interview, the DON stated anytime a nurse entered and exited a resident's room, they should have washed their hands or used an appropriate alcohol based product. The DON stated it was important to do this to prevent infection spreading from one patient to another and also the staff. A review of the facility's policy titled, Hand Washing-Hand Hygiene, dated 8/2017, indicated, . 2. Personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. When indicated, employees must wash hands for at least twenty (20) seconds using antimicrobial or non-antimicrobial soap and water 055964 Page 18 of 18