Health inspection·November 26, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Licensed Vocational Nurses (LVNs) 2 and 3 administered 9 a.m. medications in a timely manner, for one of three sampled residents (Resident 4).These deficient practices resulted in Resident 4 not receiving his scheduled 9 a.m. medications on time on 11/15/2025 and 11/16/2025. These deficient practices had the potential of causing increased risk of harm to Resident 4 due to potential underdosing or overdosing, which could lead to unstable blood pressure, heart complications, and unnecessary discomfort.Findings:During a review of Resident 4's admission Record (Face Sheet), the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included type 2 Diabetes Mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing) congestive heart failure ([CHF]heart disorder that causes the heart to not pump the blood effectively, sometimes resulting in leg swelling) and atrial fibrillation (an abnormal heart rhythm) .During a review of Resident 4's Minimum Data Set ([MDS] a resident assessment tool), dated 10/30/2025, the MDS indicated Resident 4's cognition (ability to think and reason) was moderately impaired and had the ability to understand and be understood by others.During a review of Resident 4's Physician's Orders, dated 11/26/2025, indicated Resident 4 was to receive the following medications:1. Valproic Acid (medication used to stabilize mood) Oral Solution 250 milligrams ([mg] unit of measurement)/5 milliliters ([ml] unit of measurement) 5 ml by mouth one time a day for mood disorder, ordered on 8/15/2025.2. Metoprolol Tartrate (medication used to lower heart rate and lower blood pressure) 12.5 mg by mouth two times a day for hypertension (high blood pressure), hold if systolic blood pressure ([SBP] measures the pressure in the arteries when the heart beats and pumps blood to the rest of the body) is less an 110 or heart rate less than 60 beats per minute, ordered on 8/14/2025.3. Potassium Chloride (supplement) Extended Release (designed to dissolve and release gradually in the body) 10 milliequivalent ([mEQ] unit of measurement) two tablets by mouth one time a day for supplement, ordered on 8/14/2025.4. Prednisone (medication, also called a steroid that works to control inflammation in the body) tablet 10 mg by mouth one time a day for chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing) exacerbation, ordered on 8/14/2025.5. Hydroxychloroquine Sulfate (medication that works by calming an overactive immune system) 200 mg by mouth one time a day for arthritis, ordered on 8/14/2025.6. Docusate Sodium (stool softener) 100 mg one capsule by mouth two times a day for bowel management, ordered on 8/14/2025.7. Furosemide (medication acts to rid body of extra salt and water by causing an increase in urination), one tablet by mouth two times a day for CHF, ordered on 8/14/2025.8. Apixaban (medication that works to prevent harmful blood clots from forming in the blood) 5 mg two times a day for cerebrovascular accident ([CVA] stroke, loss of blood flow to a part of the brain) prophylaxis, ordered on 8/14/2025.9. Cyanocobalamin (Vitamin B-12, supplement) 1000 micrograms ([mcg] unit of measurement) by mouth one time a day for supplements, ordered on 8/14/2025.10. Gabapentin (medication used to calm overactive nerves, Residents Affected - Some Page 1 of 3 056104 056104 11/26/2025 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some helping to treat nerve pain and control certain types of seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) 100 mg, by mouth one time a day for neuropathy (nerve damage that can cause pain, tingling, numbness or weakness), ordered on 8/14/2025.11. Calcitonin (Salmon) (medication used to treat weakened bones (osteoporosis) in women who have gone through menopause Nasal Solution 200 unit/ACT 1 spray alternative nostrils once a day for osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D), ordered on 8/14/2025.During a review of Resident 4's Medication Administration Audit Report (a document indicating the exact time medications were documented and administered), dated 11/26/2025, indicated Resident 4 was to receive the following medications on 11/15/2025:1. Valproic Acid was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Valproic Acid at 10:38 a.m. (over one hour after the scheduled dose). 2. Metoprolol Tartrate was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Metoprolol at 10:42 a.m. (over one hour after the scheduled dose). 3. Potassium Chloride was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Potassium at 10:43 a.m. (over one hour after the scheduled dose).4. Prednisone was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Prednisone at 10:43 a.m. (over one hour after the scheduled dose). 5. Hydroxychloroquine Sulfate was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Hydroxychloroquine at 10:42 a.m. (over one hour after the scheduled dose). 6. Docusate Sodium was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Docusate at 10:42 a.m. (over one hour after the scheduled dose) 7. Furosemide was scheduled to be administered at 9 a.m., however, the report indicated that LVN 2 documented that she administered Furosemide at 10:42 a.m. (over one hour after the scheduled dose). 8. Apixaban was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Apixaban at 10:42 a.m. (over one hour after the scheduled dose). 9. Cyanocobalamin was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Cyanocobalamin at 10:42 a.m. (over one hour after the scheduled dose). 10. Gabapentin was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented she administered Gabapentin at 10:42 a.m. (over one hour after the scheduled dose). 11. Calcitonin was scheduled to be administered at 9 a.m., however, the report indicated LVN 2 documented that she administered Calcitonin at 10:44 a.m. (over one hour after the scheduled dose). During a subsequent review of Resident 4's Medication Administration Audit Report (a document indicating the exact time medications were documented and administered) dated 11/26/2025, Resident 4 was to receive the following medications on 11/19/2025:1. Apixaban was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Apixaban at 11:56 a.m. (almost three hours after the scheduled dose). 2. Cyanocobalamin was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Cyanocobalamin at 11:56 a.m. (almost three hours after the scheduled dose).3. Gabapentin was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Gabapentin at 11:56 a.m. (almost three hours after the scheduled dose). 4. Calcitonin was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Calcitonin at 11:57 a.m. (almost three hours after the scheduled dose).5. Furosemide was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented that she administered Furosemide at 11:56 a.m. (almost three hours after the scheduled dose). 6. Hydroxychloroquine was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered 056104 Page 2 of 3 056104 11/26/2025 Rose Villa Health Care Center 9028 Rose Street Bellflower, CA 90706

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Hydroxychloroquine at 11:56 a.m. (almost three hours after the scheduled dose). 7. Valproic Acid was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented that she administered Valproic Acid at 11:55 a.m. (almost three hours after the scheduled dose). 8. Metoprolol was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Metoprolol at 11:55 a.m. (almost three hours after the scheduled dose). 9. Potassium Chloride was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented that she administered Potassium at 11:55 a.m. (almost three hours after the scheduled dose).10. Prednisone was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Prednisone at 11:55 a.m. (almost three hours after the scheduled dose).11. Docusate was scheduled to be administered at 9 a.m., however, the report indicated LVN 3 documented she administered Docusate at 12:03 p.m. (three hours after the scheduled dose). During an interview on 11/26/2025, at 3:50 p.m. LVN 2 stated on 11/15/2025 she administered Resident 4's 9 am scheduled medications late due to the facility being short staffed that day. LVN 2 stated the facility policy states medications can be given up to one hour before or one hour after the scheduled time. LVN 2 stated administered medications after the scheduled time leads to potential risk of overdosage or underdosage of medication.During an interview on 11/26/2025, at 4:05 p.m. LVN 3 stated on 11/19/2025 she administered Resident 4's 9 a.m. scheduled medications about three hours late due to being busy with other residents. LVN 3 stated she did not ask for help from her coworkers because everyone seemed busy.During an interview on 11/26/2025, at 4 p.m., the DON stated when residents do not receive their medications on time as prescribed and scheduled, the resident is at risk for underdosage or overdosage if the medications are given too close together. The DON stated that administering certain medications late that directly affect the heart rate and blood pressure can cause harm to the resident. The DON stated, the although the licensed nurses are instructed to ask for help when they anticipate they are falling behind on administering medications, they often choose not to ask for assistance. The DON stated that the facility will call in additional nurses to work to cover shifts that are short staffed. The DON stated she was not aware of any short staffing on 11/15/2025 or 11/19/2025.During a review of the facility's Policy and Procedure (P&P) titled, Medications Administration, revised 2012, the P&P indicated medications are administered within 60 minutes of scheduled time, except before or after meals orders, which are administered based on mealtimes. 056104 Page 3 of 3