Health inspection·June 24, 2024

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 safe and secure storage of medications for one of three sampled residents (Resident 2) as indicated in the facility's policies and procedures (P&P) titled, Self-Administration of Medications, and Medication Labeling and Storage. This deficient practice had the potential for other residents and unauthorized persons to access Resident 2's medications. Findings: During a review of Resident 2's admission Record (AR), the AR indicated, the facility admitted Resident 2 on 11/22/2021, with diagnoses of hypothyroidism (a condition where the thyroid [a gland that regulates growth and metabolism] does not create and release enough thyroid hormone in the bloodstream), essential (primary) hypertension (a form of high blood pressure that is linked to genetics, poor diet, lack of exercise, and obesity), and type 2 diabetes mellitus (characterized by high levels of blood sugar in the blood). During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/21/2024, the MDS indicated, Resident 2 was understood by others and had the ability to understand others. The MDS indicated, Resident 2 required substantial/maximal assistance (helper lifted or held trunk or limbs and provided more than half the effort) with eating, oral hygiene, toileting hygiene, showering/bathing self, upper and lower body dressing, and personal hygiene. During a concurrent observation and interview on 6/21/2024 at 2:57 pm with Resident 2, in Resident 2's room, there were two bottles of Laxaclear (used to treat constipation), one bottle of Senokot (used to treat constipation), one bottle of vitamin c 500 milligrams (mg - a measure of weight) tablets, and one bottle of MiraFIBER gummies (a source of fiber supplement) at Resident 2's bedside. Resident 2 stated the medications belonged to Resident 2 and Resident 2 was not able to self-administer them. During an interview on 6/21/2024 at 3:06 pm with the Infection Preventionist Nurse (IPN), the IPN stated Resident 2 preferred having/storing the medications at Resident 2's bedside. The IPN stated Resident 2 was unable to move both Resident 2's upper extremities and the licensed nurses had to administer the medications to Resident 2. During an interview on 6/21/2024 at 3:35 pm with the Administrator (ADM), the ADM stated Resident 2 Page 1 of 2 055992 055992 06/24/2024 West Covina Healthcare Center 850 S. Sunkist Ave. West Covina, CA 91790

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was unable to self-administer medications. The ADM stated it was unsafe to have medications stored at Resident 2's bedside because any other residents could grab the medications from the bedside table. During a review of the facility's P&P titled, Self-Administration of Medications, revised in February 2021, the P&P indicated, any medications found at bedside that were not authorized for self-administration were turned over to the nurse in charge for return to the family or responsible party. During a review of the facility's P&P titled, Medication Labeling and Storage, revised in February 2023, the P&P indicated, the facility stored all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. 055992 Page 2 of 2