Health inspection·July 18, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to obtain medication for one of three sampled residents (Resident 1) when Fosamax (a medication used to prevent and treat osteoporosis [thinning of the bone]) was not available for administration to Resident 1. The failure to obtain and administer ordered medication had the potential to result in ineffective treatment and pain. Findings: A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in May 2021, with diagnoses of quadriplegia (paralysis of all four limbs) and osteoporosis. A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 3/1/24, indicated a score of 15 on the Brief Interview for Mental Status (BIMS, an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS score ranges from 0-15, with 15 as an indication of intact skills). A review of Resident 1's Order Details indicated the following medication orders: - Dated 5/23/24, at 23:00, the order summary indicated Fosamax Oral tablet 70 milligrams (mgs) (Alendronate Sodium). Give 1 mg by mouth every Monday (first dose on 5/27/24) for Osteoporosis. This order was discontinued on 5/23/24, at 23:08. - Dated 5/23/24, at 23:08, the order summary indicated Fosamax Oral tablet 70 milligrams (mgs). Give 1 mg by mouth in the morning every Friday (first dose on 5/24/24) for Osteoporosis. This order was discontinued on 5/23/24, at 23:09. - Dated 5/23/24, at 23:09, the order summary indicated Fosamax Oral tablet 70 milligrams (mgs). Give 1 mg by mouth every Monday (first dose on 5/27/24) for Osteoporosis. A review of Resident 1's Medication Administration Record (MAR) dated May 2024, indicated, Fosamax Oral tablet 70 milligrams (mgs) .Give 1 mg by mouth in the morning every Friday (Fri) for osteoporosis .Start Date 5/24/24 0600. Resident's MAR dated 5/24/24 and 5/31/24 had entries to indicate Registered Nurse 1 (RN 1) had administered the Fosamax scheduled for 0600 a.m. A review of Resident 1's MAR dated June 2024, indicated, Fosamax Oral tablet 70 milligrams (mgs) .Give 1 mg by mouth in the morning every Friday (Fri) for osteoporosis. Resident's MAR dated 6/7/24 Page 1 of 2 056052 056052 07/18/2024 Eden Healthcare Center 27350 Tampa Avenue Hayward, CA 94544

F 0755 and 6/14/24 had entries to indicate RN 1 had administered the Fosamax scheduled for 0600 a.m. Level of Harm - Minimal harm or potential for actual harm A review of the Pharmacy Manifest dated 6/16/24, at 12:50 a.m., indicated Resident 1's new order of Alendronate Sodium (Fosamax) 70 mg, four tablets was delivered to the facility. Residents Affected - Few During a concurrent telephone interview and record review on 6/19/24, at 4:18 p.m., with RN 1, Resident 1's MAR dated May 2024 and June 2024 were discussed. RN 1 stated Resident 1's supply of Fosamax was available for administration and RN 1 was able to administer the Fosamax to Resident 1 on 5/24/24, 5/31/24, 6/7/24, and 6/14/24 as RN had initialed accordingly in the MAR. During an interview with Resident 1 on 6/19/24, at 4:34 p.m., Resident 1 denied receiving the Fosamax from any licensed nurse ever since the new medication was ordered in May 2024. Resident 1 further stated Licensed Vocational Nurse 1 (LVN 1) informed her that resident's Fosamax had just come in from the pharmacy at this date, 6/19/24. During a telephone interview on 7/16/24, at 11:38 a.m., with the Director of Nursing (DON), DON stated when the physician gives a new medication order, license nurse should carry out the order, notify the pharmacy of the new order, and administer the drug as ordered to the resident. If medication is still unavailable for administration, follow up with pharmacy, notify the physician, resident, and/or the Resident Representative (RR). A review of the facility's policy and procedure (P&P) titled, Unavailable Medications, dated 6/1/2023, indicated, This facility shall use uniform guidelines for unavailable medications .Medications may be unavailable for a number of reasons. Staff shall take action when it is known that the medication is unavailable: a. Determine reason for unavailability, length of time medication is unavailable, and what efforts have been attempted by the facility or pharmacy provider to obtain the medication. B. Notify physician of inability to obtain medication upon notification or awareness that medication is not available. If a resident misses a scheduled dose of the medication, staff shall notify the Medical Doctor (MD) and resident/responsible party as indicated. A review of the facility's P&P titled, Medication Administration, dated 6/15/2023, indicated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice . 056052 Page 2 of 2