Health inspection·April 24, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed follow their policy and procedures (P&P) and to assure that services being provided met professional standards of quality for one of four residents, (Resident 1), when a Licensed Nurse (LN 1) administered medication four hours late, improperly disposed of medication and incorrectly documented these errors. Residents Affected - Few These deficient practices had the potential to cause harm and have a negative impact on the intended therapeutic effect of the medications. Findings: A review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted in January of 2025, with diagnoses that included Rhabdomyolysis (rare muscle injury where your muscles break down), Bariatric surgery status, (patient had undergone a bariatric procedure, such as gastric banding or bypass), and Hypomagnesemia (low magnesium levels in the blood. Magnesium is an essential mineral for energy production, muscle and nerve function, bone health and blood pressure regulation). During a concurrent observation and interview with LN 1 at Nurses Station 2, on 4/24/25 at 1:40 p.m., LN 1 stated Resident 1 had not taken her scheduled medications doses at 8 a.m. and 9 a.m. LN 1 accessed her medication cart, removed Resident 1 ' s medications from the cart, placed them inside a medication cup, poured MiraLAX into another cup, and instructed Resident 1 to take her medications. Resident 1 took all her medications except for the MiraLAX, and the LN 1 disposed of the MiraLAX in the trash. LN 1 confirmed Resident 1 ' s medications were administered late and that she disposed of the MiraLAX in the trash. LN 1 stated that it was not good practice to dispose of medications in the trash because the medication could be removed and ingested by a person it was not intended for and could have a harmful effect on them. During an interview with the Director of Nursing (DON) on 4/24/25 at 3:59 p.m., the DON confirmed LN 1 administered Resident 1 ' s medications after the scheduled time. The DON stated her expectation was for the nurses to follow the physician ' s order and to inform the physician if the resident refused to take their medications. The DON stated LN 1 should not have disposed of the medication in the trash as they were trained to discard medications in their drug buster container (drug disposal system) inside their medication carts. The DON emphasized the importance of properly disposing medications as the medications may cause damaging effects to a resident if taken without a physician ' s order. During a review of Resident 1 ' s Medication Administration Record (MAR) on 4/24/25, the MAR indicated Resident 1 ' s following medications were scheduled to be given every day at 8 a.m.: Page 1 of 2 056238 056238 04/24/2025 Solano Post Acute 2200 Tuolumne Street Vallejo, CA 94589

F 0658 Ascorbic Acid (Vitamin C), Level of Harm - Minimal harm or potential for actual harm Calcium Citrate (helps build strong bones), Vitamin D, Docusate Sodium (laxative), Residents Affected - Few Ferrous Gluconate (iron supplement), Folic Acid (also known as Vitamin B9), Magnesium Oxide (supplement used to treat migraine and constipation), Multi Vitamin, MiraLAX, and Sennosides (stool softener). The following medications for Resident 1 were scheduled to be given every day at 9 a.m.: Pantoprazole Sodium (reduces the amount of acid in the stomach), B-12 (Vitamin), Vitamin D, Vitamin A, and Thiamin HCL (Vitamin). A further review of the MAR for April indicated that all medications scheduled for 8 a.m. and 9 a.m. on 4/24/25 were inaccurately documented by LN 1 as given timely and not when they were actually administered at 1:40 p.m. The 8 a.m. dose of MiraLAX from 4/24/25 was documented as given when it had been disposed. During a phone interview with the Assistant Director of Nursing (ADON) on 4/29/25 at 3:55 p.m., the ADON confirmed as documented in Resident 1 ' s MAR, there was a check mark and initial of LN 1 on 4/24/25 at 8 a.m., which indicated MiraLAX was consumed by Resident 1. The ADON stated, it is not safe to indicate a certain task was performed if it was not done. A review of the facility ' s P&P, titled, Physician Order, dated 3/22/22, indicated, . VIII. the Licensed Nurse receiving the order will be responsible for documenting and implementing the order . A review of the facility ' s P&P, titled, Discarding and Destroying Medications, dated November 2022, indicated, Medications that cannot be returned to the dispensing pharmacy (e.g., non unit-dose medications, medication refused by the resident, and/or medications left by residents upon discharge) are disposed of in accordance with federal, and state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances . 056238 Page 2 of 2