Health inspection·August 25, 2025

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 interview, and record review, the facility failed to ensure:1) Licensed Vocational Nurse (LVN) 1 verified all medications, including controlled substance medications, received from pharmacy were checked and accounted for accuracy.2) LVN 2 and LVN 5 did not sign the narcotic count sheets ahead of time indicating that they (LVN 2 and LVN 5) actually counted and confirmed with the oncoming licensed nurse that the narcotics count was accurate/correct during shift change narcotics count. These deficient practices of not verifying medications received from pharmacy were accurate and not signing out on the narcotic sheets without counting/verifying with another licensed nurse present had the potential for diversion of narcotics. Findings: During a record review, the facility's In-Service Education (a professional development for workers aimed to enhance their skills, knowledge, and competence to improve job performance) dated 5/09/2025 indicated, several LVNs and RNs received education on Medication Order and Receiving. The education's lesson plan indicated all licensed nurses verify and document medications, including controlled substance, were received. The lesson plan also indicated that all licensed nurses will promptly report any discrepancies and omissions to the pharmacy and the charge nurse/supervisor. During a record review, the facility pharmacy receipt dated 8/20/2025, indicated the pharmacy receipt was signed by LVN 1 on 8/21/2025. During a record review, the facility pharmacy receipt dated 8/21/2025, indicated the pharmacy receipt was signed by a licensed nurse on 8/21/2025 at 6:24 PM. During a record review, LVN 1's timecard dated 8/16/2025 through 8/31/2025 of, indicated, LVN 1 clocked in on 8/20/2025 at 11:04 PM and clocked out on 8/21/2025 at 7:58 AM. During a record review, the Notice of Investigatory Suspension letter addressed to LVN 1 dated 8/21/2025, indicated, LVN 1 was suspended effective 8/21/2025. During a record review, the facility document titled One on One Education/Retraining (a type of training where a professional trainer guides a single individual through a session, tailoring the program to their specific goals, needs, and fitness level) dated 8/21/2025, indicated, LVN 1 received education on Receiving Controlled Medications. The lesson plan for retraining education indicated that a nurse signs for the medications received from pharmacy and inspects the medications and reconciles controlled substance orders.against what has been received from the pharmacy. During a record review, the Pharmacy's Management record, dated 8/22/2025, indicated, while the medication (tramadol) did appear on the packing slip (pharmacy receipt), it was unfortunately not in the delivery bag. We have since located the medication and ensured it was redelivered to [the facility]. During a record review, the facility Medication Cart 1 Narcotic Sheet dated 8/25/2025, indicated LVN 2 had already signed out on the narcotic sheet before the end of LVN 2's shift. During a record review, the Medication Cart 1 Narcotic Sheet dated 8/25/2025, indicated LVN 5 had already signed out on the narcotic sheet before the end of LVN 5's shift. During a concurrent record review and interview on 8/25/2025 at 10:53 AM with LVN 5, Medication Cart 2 narcotic sheet dated 8/25/2025, was reviewed. When LVN 5 was asked why a narcotic sheet require two licensed nurses' signatures on it, LVN 5 stated their signatures tell Page 1 of 3 056321 056321 08/25/2025 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few everyone they both checked the medications together and everything is accounted for. Medication Cart 2 narcotic sheet dated 8/25/2025 indicated LVN 5 had already signed the narcotic sheet ahead of time and before end of LVN 5's shift. LVN 5 was asked why the 8/25/2025 narcotic sheet was signed ahead of time, LVN 5 stated it was a mistake. LVN 5 stated the narcotic sheet should have been signed at the end of the shift, around 3 pm today (8/25/25) with another nurse. LVN 5 stated the signatures of two licensed nurses on the medication cart 2 narcotic sheet indicated the signatures of the nurses verify they counted the medications together. LVN 5 also stated the potential harm to Resident 1 when the medication cart 2 narcotic sheet was signed ahead of time that the medication may be missing, the resident has to wait for the medication replacement causing resident additional pain and discomfort. During a concurrent record review and interview on 8/25/2025 at 12:14 PM with LVN 2, LVN 2 was asked if it was acceptable to sign the narcotic sheet ahead of time, LVN 2 stated no.if the narc sheet is signed ahead of time, then it means the nurse didn't really check the medications with another nurse. Medication Cart 1 narcotic sheet for 8/25/2025 was signed by LVN 2 ahead of time. LVN 2 was asked why LVN 2 signed the medication cart 1 narcotic sheet ahead of time, LVN 2 stated that was a mistake. LVN 2 also stated the potential harm to the resident when the medication cart 1 narcotic sheet was signed ahead of time the resident's med may be missing.causing the resident to have increased pain and suffering.may need additional pain medication when the resident's pain is not relieved by the pain medication replacement. During an interview on 8/25/2025 at 12:14 PM with LVN 2, LVN 2 stated the licensed nurse who received medication delivery from the dispensing pharmacy did not check to verify against the pharmacy receipt against what medications were actually delivered to the facility. LVN 2 stated, there is a high chance which medications actually came, and which ones did not come. During an interview on 8/25/2025 at 1:24 PM with Registered Nurse Supervisor (RNS) 1, RNS 1 stated, it is important to check the medications received against the pharmacy receipt to verify and account for all the medications received.sometimes the wrong information is on the receipt - wrong name for wrong medication. During a phone interview on 8/25/2025 at 2:04 PM with LVN 1, LVN 1 stated when receiving medication delivery (brown bag) from pharmacy, make sure everything that is on the pharmacy receipt matches with the medications being delivered. LVN 1 stated when LVN 1 received the delivery bag from the pharmacy on 8/21/2025 between approximately 4:40 am and 4:45 am, I looked at the bubble packs (a medication packaging system that contains individual doses of medication per bubble) then I signed the receipt, it looked right to me that's why I signed the receipt. LVN 1 stated that before LVN 1 handed the medication key to the next shift nurse at the end of LVN 1's shift (11 pm to 7 am), LVN 1 realized there was one medication missing, tramadol (a strong narcotic medication used to treat moderate to severe pain). LVN 1 stated LVN 1 panicked when LVN 1 realized tramadol was not in the brown bag I asked my two co-workers if they received any narcotics from the pharmacy.both said no. LVN 1 also stated LVN 1 called the pharmacy, but no one answered so LVN 1 left a message, the facility's Director of Nursing (DON) was immediately notified about the missing tramadol. LVN 1 was suspended for only one day on 8/21/2025 my drug test was negative, and the narcotic was found.on 8/21/2025. When asked if LVN 1 knew the whereabouts of the narcotic tramadol, LVN 1 stated the Director of Nursing (DON) told LVN 1 that the tramadol was delivered to another facility. During an interview on 8/25/2025 at 3:19 PM with DON, DON confirmed LVN 1 notified the DON right away about the missing narcotic, tramadol on 8/21/2025 as [LVN 1] was getting ready to leave at the end of [LVN1's] shift. DON also confirmed and stated LVN 1 was suspended pending their investigation because the medication was a Class IV Controlled Substance and that we couldn't find the [tramadol]. DON stated LVN 1's suspension was lifted after the narcotic tramadol was found on 8/21/2025 by the pharmacy staff. 056321 Page 2 of 3 056321 08/25/2025 Olympia Convalescent Hospital 1100 S. Alvarado St Los Angeles, CA 90006

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DON stated the narcotic, tramadol, was delivered to another facility by mistake by the pharmacy staff. DON stated the expectations from licensed nurses when receiving any type of medication from pharmacy was for nurses to check the pharmacy receipt against the medications received, after confirming verification, the nurses can then sign the receipt. DON stated signing the narcotic sheet ahead of time is not part of the facility policy, the nurse does not know if there are any situations happening that may cause the count to be inaccurate. DON added when the oncoming and outgoing nurses signed on the narcotic sheet, that means both nurses counted the narcotics and that they endorsed (gave report to) on each other. DON confirmed there were two nurses (LVN 2 and LVN 5) who signed out of the narcotic sheets ahead of time. During a record review, the facility Policy and Procedures (P&P - policy explains the rules and presents them in a logical framework while procedures outline the step-by-step implementation of various tasks) titled Medication Storage in the Facility - Controlled Medication Storage with an effective date of 01/2022, indicated, Two licensed nurses do a physical inventory of all controlled substances at each shift change and documented on the narcotic sheet. During a record review, the facility's undated P&P titled Medication Storage in the Facility -Ordering and Receiving Non-Controlled Medications from the Dispensing Pharmacy indicated, A licensed nurse who received medications delivered by the pharmacy verifies medications received and promptly reports discrepancies and omissions to the to the issuing pharmacy and the supervisor. 056321 Page 3 of 3