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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to maintain an accurate record of Norco (a
controlled medication that combines two types of drugs, acetaminophen and hydrocodone, for pain
management) for one of five sample residents (Resident 4) when a Licensed Vocational Nurse (LVN1)
administered Norco to Resident 4 and failed to document.
This failure had the potential in delaying the recognition of possible diversion of a control medication.
Findings:
During a review of Resident 1 Face Sheet (contain resident demographic), the Face Sheet indicated
Resident 1 was admitted to the facility on [DATE], with a diagnosis that included Hemiparesis (one-sided
muscle weakness), Dysphagia (difficulty swallowing), Hypertensive (high blood pressure) heart disease.
A review of Resident 4's Orders, dated November 30, 2024, indicated, Norco 5-325 milligram (mg-unit
dosing medication, a combination of 325 mg of acetaminophen and 5 mg of hydrocodone) was ordered to
be given as needed for moderate pain (pain scale to evaluate pain level of patients).
A review of the controlled drug log for Resident 4 indicated that Narco oral tablets, 5-325 mg, were
administered on the following dates and times: December 1, 2024, at 09:10; December 2, 2024, at 01:50,
09:00, and 21:52; December 3, 2024, at 03:30 and 08:30; December 4, 2024, at 05:20; December 5, 2024,
at 04:25 and 09:00; December 6, 2024, at 02:45 and 09:00; December 7, 2024, at 09:00; December 8,
2024, at 09:00; December 10, 2024, at 05:90; December 11, 2024, at 09:00; December 12, 2024, at 04:36
and 09:00; and December 13, 2024, at 05:30.
A review of Resident 4's eMAR indicated that Narco oral tablets, 5-325 mg, were administered on the
following dates and times: December 2, 2024, at 0116 hours; December 2, 2024, at 2126 hours; December
3, 2024, at 0329 hours; December 3, 2024, at 0814 hours; December 4, 2024, at 0518 hours; December 5,
2024, at 0425 hours; December 6, 2024, at 0243 hours; December 10, 2024, at 0544 hours; December 12,
2024, at 0436 hours; and December 13, 2024, at 0519 hours.
During concurrent telephone interview and record review on December 17, 2024 at 11:08 AM, with the
Director of Nursing (DON 1), Resident 4's eMAR and controlled drug book were reviewed. The DON 1
confirmed that on the following dates and times-December 1, 2024, at 9:00 AM; December 2, 2024, at 9:00
AM; December 5, 2024, at 9:00 AM; December 6, 2024, at 9:00 AM; December 7, 2024, at 9:00 AM;
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
056136
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056136
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
12/13/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Villa Mesa Care Center
867 E. 11th St
Upland, CA 91786
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
December 8, 2024, at 9:00 AM; December 11, 2024, at 9:00 AM; and December 12, 2024, at 9:00
AM-medications were documented as administered in the controlled drug book but were not recorded in
the eMAR. Additionally, she emphasized that LVN1 should be aware that when administering narcotics, it is
essential to sign both the eMAR and the controlled drug book.
During concurrent telephone interview and record review on December 17, 2024 at 11:26 AM with LVN 1.
The eMAR and controlled drug book for Resident 4 were examined. LVN 1 confirmed that she had recorded
in the control book the administration of Narco to Resident 4, but did not sign the eMAR for these
administrations on the following dates and times: December 1, 2024, at 0900; December 2, 2024, at 0900;
December 5, 2024, at 0900; December 6, 2024, at 0900; December 7, 2024, at 0900; December 8, 2024,
at 0900; December 11, 2024, at 0900; and December 12, 2024, at 0900. LVN 1 indicated that, according to
policy, it is mandatory to sign the eMAR whenever medication is administered, and both the eMAR and the
Narcotic Control Book must be signed for narcotics. She emphasized that failing to sign the eMAR when
administering medication is unacceptable. LVN 1 further stated the fact that she didn't sign the eMAR was a
coincidence. She claimed to have signed the eMAR for other medications, but she was unable to provide an
explanation for why it was a coincidence that she did not sign the eMAR for narcotics alone. She
acknowledged that the signatures on the eMAR are essential for verifying that medications have been
administered, while the signatures in the Narcotic Control Book are necessary to ensure accurate
medication counts.
A review of the facility Policy & Procedure (P&P) titled, Documentation of Medication Administration
indicated, .I. A nurse or certified medication aide (where applicable) documents all medications
administered to each resident on the resident's medication administration record (MAR). 2. Administration
of medication is documented immediately after it is given .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056136
If continuation sheet
Page 2 of 2
