Health inspection·May 12, 2025

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 not left unattended for one resident (Res 1). This failure had the potential to affect Resident 1 ' s safety and staff drug diversion. Findings. A record review of the facility ' s undated admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included Atrial Fibrillation (irregular rapid heart rate) and Urinary Tract Infection (bladder infection). An observation during a facility reported investigation on 5/12/24 at 10:00 A.M., in Resident 1 ' s room was conducted. Resident 1 had multiple number of medications, inside a small clear cup sitting on Resident 1's bedside table. Resident 1 stated, I think the nurse left the medications there for me to take, but I was still asleep. Resident 1 stated she did not know what the medications were and what they were for. A review of Resident 1 ' s minimum data set( MDS- federally mandated assessment tool) dated 2/3/25 indicated Resident 1 ' s brief interview for mental status (BIMS) score was 12 which meant Resident 1 ' s cognition (thought process) was intact. A joint interview and record review on 5/12/25 at 11 A.M., with Licensed Nurse (LN) 1 was conducted. LN 1 discussed the following medications listed on Resident 1 ' s Medication Administration Record( MAR). LN1 stated she had left the medications in a cup and placed on Resident 1 ' s bedside table. An observation of Medications at Resident 1's bedside were reconciled with Resident 1's MAR during an interview with LN 1. Amiodarone 200 mg ,give 1 tablet twice a day -Arrythmias. Check apical pulse .Hold if below 60. Cholecalciferol 50 mg by mouth one time a day for Supplement Co-enzyme Q10, 100 mg by mouth two times a day for Supplement Page 1 of 2 056040 056040 05/12/2025 Escondido Post Acute 421 E Mission Ave Escondido, CA 92025

F 0761 Doxycycline 100 mg , give 1 tablet twice a day for Pneumonia x 10 days Level of Harm - Minimal harm or potential for actual harm Duloxetine 30 mg , give 1 capsule by mouth one time a day for Depression Eliquis 5 mg , give I tablet by mouth two times a day for Atrial Fibrillation Residents Affected - Few Ferrous sulfate 325 mg , 1 tablet by mouth one time a day for Supplement Florastor 250 mg , I capsule by mouth two times a day for Supplement Lasix 40 mg , give 1 tablet one time a day for Fluid retention Metoprolol 25 mg , 1 tablet by mouth two times a day for Hypertension Midodrine 25 mg, 1 tablet by mouth two times a day for Hypotension Mirabegron 24-hour 50 mg , give 1 tablet by mouth one time a day for Overactive bladder. Do not crush or chew. Mucinex 12 hours , give 600 mg by mouth two times a day for chest congestion x 7 days Multivitamin , give 1 tablet by mouth one time a day for Supplement Oxybutynin 15 mg , give 1 tablet one time a day for Bladder management Potassium Chloride 10 meq , give 1 tablet by mouth twice a day for Supplement. Give medication with food or snacks and/or with 4-8 oz of water or juice to prevent Gastrointestinal upset. Pregabalin 75 mg , give 1 capsule by mouth twice a day for pain Sertraline 50 mg , give 1.5 tablet by mouth one time a day for Depression. Ticagrelor 90 mg , give 1 tablet by mouth twice a day for Clot prevention LN 1 stated she was distracted when another resident was yelling, and she went to check on the other resident and left the medications for Resident 1 at bedside. LN 1 stated there were 19 medications that she had left unattended. LN 1 stated it was important not to leave medications unattended in a resident room for resident safety. LN 1 stated some of the medications required certain instructions before administration like apical pulse (pulse that is measured by listening to the heart directly with a stethescope) check, and instruction that include, do not crush or chew and to take medication with snack or water. An interview on 5/12/24 at 11:30 A.M., with the Director of Nursing (DON) was conducted. The DON stated medications are not to be left unattended anywhere in the facility including resident ' s rooms for their safety and to prevent drug diversion. A review of the facility ' s policy titled, Medication Labeling and Storage dated 2/2023 indicated, Medication Storage . 2. The nursing staff is responsible for maintaining medication storage and preparation in a clean, safe and sanitary manner. 056040 Page 2 of 2