Health inspection·November 8, 2024

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 to ensure safe medication administration to one resident (Resident 1) of two sampled residents when medications were left unattended at bedside. Residents Affected - Few This decreased the facility's potential to ensure medications were safely ingested by the intended resident. Findings: A review of an admission record indicated Resident 1 was admitted to the facility in 2024 with diagnoses which included anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress) and chronic pain syndrome (a condition that involves chronic pain that interferes with daily life and is accompanied by other symptoms). A review of Resident 1's care plan initiated on 7/31/24 indicated a focus on, Resident accusing NOC [nocturnal shift] nurse of not giving her medications that were scheduled . Licensed nurses were supposed to, increase communication between [Resident 1] .about care and living environment .Explain all procedures and .medications . A review of Resident 1's care plan initiated on 8/27/24 indicated a focus on, [Resident 1] yelling at NOC CNA [Certified Nurse Assistant] and this nurse and accusing NOC CNA and this nurse of not providing care to resident .Resident also throwing her medication at this nurse. Licensed nurses were supposed to, increase communication between [Resident 1] .about care and living environment .Explain all procedures and .medications . A review of Resident 1's self-administration of medication dated 10/13/24 at 1:40 a.m. indicated no members of the interdisciplinary team (IDT, a group of health professionals from different disciplines who work together to treat a patient) was documented. In an observation on 11/8/24 at 2:05 p.m. in Resident 1's room, an open medication cup labeled with Resident 1's room number and bed sat on a food tray next to various food items. The medication cup had no lid and approximately 9 pills of different colors and sizes. The surveyor took a photo of the medication cup. In an interview and concurrent record review on 11/8/24 at 3:30 p.m., the Director of Nursing (DON) was shown the photo of the medication cup with Resident 1's room number and bed. The DON stated leaving medications at bedside was a safety concern because the licensed nurse could not ensure what Resident 1 would do with the medications. The DON also confirmed Resident 1's self-administration of Page 1 of 2 056304 056304 11/08/2024 Mission Carmichael Healthcare Center 3630 Mission Avenue Carmichael, CA 95608

F 0658 Level of Harm - Minimal harm or potential for actual harm medication assessment was incomplete. The DON was unable to provide any IDT notes regarding Resident 1's ability to self-administer medication. A review of Resident 1's active physician orders printed on 11/8/24 at 4:02 p.m. indicated no active order which indicated Resident 1 was able to self-administer medications. Residents Affected - Few A review of all of Resident 1's care plans on 11/8/24 indicated no documented evidence of a care plan for Resident 1's ability to self-administer medications. In a concurrent observation and interview in Resident 1's room on 11/8/24 at 4:07 p.m., Licensed Nurse 1 (LN 1) confirmed the medication cup with Resident 1's room number and bed still sat on the food tray with pills inside it. In an interview on 11/8/24 at 4:35 p.m., the Administrator and DON both stated it was not a good idea for medication to be left at bedside, unattended as it posed a safety hazard. A review of the facility's policy and procedure (P&P) titled Resident Self-Administration of Medication revised 12/19/22 indicated, .The care plan must reflect resident self-administration and storage arrangements for such medications. A review of the facility's P&P titled Administering Medications revised April 2008 indicated, .Medications may not be prepared in advance and must be administered within one (1) hour of their prescribed time .The individual administering the medication must ensure that the .right time .[is] verified before the medication is administered .Should a drug be withheld, refused, or given other than at the scheduled time, the individual administering the medication must initial and circle the MAR [Medication Administration Record] space provided for that particular drug. Any explanatory note on the reverse side of the MAR must be entered when drugs are withheld, refused, or given other than at scheduled times .Self-administration of drugs is permitted only when approved by the attending physician and interdisciplinary team assessment indicates the resident is capable of safe administration. 056304 Page 2 of 2