Health inspection·September 26, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medications were properly stored in accordance with facility ' s policies and procedures and standards of practice when one of three residents, Resident 3 was observed to have these medications stored at his bedside unlocked: 1. One opened bottle of Genvoya (used to treat infections). 2. An injection pen of Ozempic (used to treat diabetes). This failure had the potential to place Resident 3 ' s health at risk for drug abuse and ingestion of unsanitary drugs. Findings: During a review of Resident 3 ' s admission Records, the record (contains demographic and medical information), indicated Resident 3 was admitted on [DATE]. With diagnoses that included type 2 diabetes mellitus (a disease of not able to control the blood sugar levels), cirrhosis of liver (a condition of damaged liver) and chronic kidney disease (a condition when the kidneys gradually stop working). During a review of Resident 3 ' s clinical record, History and Physical dated August 7, 2023, indicated, . Assessment: . 7. HIV (human immunodeficiency viruses (a disease that destroys the cells that fight infection in the body) positive Z21 . During an observation and interview on September 11, 2024, at 9:40 AM, with Resident 3, Resident 3 stated, I keep the medicines here with me (Resident 3 reached for a plastic bag lying on his bed took out a bottle of Genvoya and an injection per of Ozempic). He stated, I keep them here (pointing at the bed) with me. During an interview on September 11, 2024, at 9:50 AM, with Licensed Vocational Nurse (LVN 1), the LVN 1 was asked if Resident 3 kept his medications by the bedside. The LVN 1 stated, Yes, he keeps the Ozempic and a bottle of Genvoya medications at the bedside, but it is a nurse that administers the medications to him. During an observation and interview on September 11, 2024, at 9:55 AM, with the Director of Nursing (DON), the DON was asked if Resident 3 kept his medications by the bedside. The DON stated, Yes, we Page 1 of 2 056024 056024 09/26/2024 Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few let him keep the Ozempic and Genvoya medications at the bedside, so he does not assume the medications are not available. During a review of Resident 3 ' s Order Summary Report included, Genvoya (medication used to treat HIV infection) tablet 150-200-10 milligram . Give 1 tablet by mouth one time a day for retroviral (medication that treats infection). During a review of Resident 3 ' s care plan dated December 23, 2021, indicated, Focus: HIV and AIDS (acquired immunodeficiency syndrome (a disease caused by HIV) at risk for complications manifested by decreased white blood cells count, fatigue, fluid volume deficit, imbalanced . Goal: will have minimal complications related to extent possible . Interventions: Administer medication as ordered . During a review of Resident 3 ' s Order Summary Report included, Ozempic (medication used to treat diabetes mellitus (0.25 or 0.5 milligram/dose [a unit of measurement) subcutaneous solution pen-injector (injection given in the tissue just under skin) 2 milligrams . inject 1 milligram subcutaneously one time a day every Wednesday for diabetes mellitus. During a review of Resident 3 ' s care plan dated September 9, 2024, indicated, Focus: .Resident requires Ozempic medication related to diabetes. Goal: Will exhibit a therapeutic effect related to the use of the medication. Interventions: Administer medication as ordered . During a concurrent interview and record review on September 11, 2024, at 11:25 PM, with the DON, the facility ' s policy and procedure (P&P), titled, Storage of Medications dated, November 2020, was reviewed. The P&P indicated, .The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications . 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner . The DON stated, We did not follow the facility policy and procedure, the medications should have been stored in a locked compartment under proper temperature. 056024 Page 2 of 2