Health inspection·April 17, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure medications were administered as ordered by the physician, for one of three sampled residents (Resident 1) when Resident 1's Midodrine HCL (medication used to treat low blood pressure, helps prevent symptoms of dizziness when a Residents or person move from a sitting to a standing position) was held and not administered on multiple occasions, on 2/16/2025, 2/20/2025, and 2/21/2025. This failure resulted in Resident 1 not getting medication to treat his low blood pressure (BP) and potential return of symptoms to manage low blood pressure such as dizziness, lightheadedness, fainting spells, including decrease or limitation in Resident 1's activities of daily function, participation in his physical therapy treatment care, increased fall risk, injury and possible hospitalization. Findings: During a review of the facility's policy and procedure (P&P), titled, Administrating Medications dated 2001, the P&P indicated, Medication shall be administered in a safe and timely manner and as prescribed . 3. Medication must be administered in accordance with the orders, including any required time frame. During a review of Resident's 1 Facesheet (FS), the FC indicated Resident 1 is [AGE] years old and was admitted to the facility in 2025. The FS also indicated Resident 1 had diagnosis of Injury at CS level of Cervical Spinal Cord (spinal cord in the neck region is damaged), Quadriplegia (partial or total loss of functions in all four limbs) , Hypotension (low blood pressure which can cause fainting or dizziness), Disorder of the Autonomic Nervous System (dysfunction of the nerves that regulate nonvoluntary body functions such as heart rate, BP), Muscle Weakness Generalized , and Depression. During a review of Resident 1's Medication Administration Record (MAR), Midodrine was not administered or held on 2/16/2025, 2/20/2025, and 2/21/2025. Resident 1's MAR indicated, Schedule for [DATE], Midodrine HCL Oral 10 MG (milligram) . Give 2 tablet via G-Tube every 8 hours for hypotension . Hold for SBP (systolic blood pressure) > (greater) 140 . start date 2/4/2025 . Sun (Feb) 16 .2100 . BP (blood pressure) 140/80 . 2 (code) . Midodrine HCL Oral 10 MG . Give 1.5 tablet via G-Tube three times a day for hypotension . Hold for SBP > 140 . start date 2/18/2025 .Thu (Feb) 20 . 0800 . BP 140/62 . 2 (code) . Fri (Feb) 21 . 2000 . BP 140/90 . 2 (code) . Resident 1's MAR also indicated, Chart Codes / Follow Up Codes . 2 = No Med Required - Outside of Parameter . During a record review and an interview on 3/21/25 at 12:09 p.m., with Unit Supervisor (US), US Page 1 of 4 056327 056327 04/17/2025 Walnut Creek Skilled Nursing & Rehabilitation Cent 1224 Rossmoor Parkway Walnut Creek, CA 94595

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated the physician's order on the MAR indicated hold Midodrine medication for Systolic Blood Pressure (SBP) greater than 140, meaning if Resident 1's SBP was at 141, then the nurse or staff passing the medication will hold the medication, but when it was at 140, the staff should have given the medication. When asked for the reason Midodrine medication was held and not given, when Resident's 1 SBP was at 140, US stated it was the facility's expectation for Licensed Vocational Nurse (LVN) 2 to have notified the Physician. US also stated LVN 2 should have documented in Resident 1's progress notes that Midodrine HCL was not given and was held because BP did not meet physician order parameters. US stated for Resident 1's Midodrine medication, facility nursing staff were trying to prevent from lowering Resident 1's BP, so if the medication was not given there is a possibility Resident 1's BP would have dropped. During an interview on 3/21/25 at 12:35 p.m., with the Administrator (ADM), ADM stated LVN 2 should have followed the physician's orders, which states on the MAR to hold for SBP greater than 140, because it's the physician's orders. During an interview on 3/21/2025 at 12:42 p.m., with LVN 2, LVN 2 stated if she had held Resident 1's medication, the process is to have notified the physician the Midodrine was held and not given, in case there is any drug interaction with the upcoming medications due to be given to Resident 1. 056327 Page 2 of 4 056327 04/17/2025 Walnut Creek Skilled Nursing & Rehabilitation Cent 1224 Rossmoor Parkway Walnut Creek, CA 94595

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 interviews and record reviews, the facility failed to ensure one of three sampled residents (Resident 1) received medications as ordered by the physician and was free of significant medication error (one which cause the resident discomfort or jeopardizes his or her health and safety), when Resident 1's Midodrine HCL (medication used to treat low blood pressure, helps prevent symptoms of dizziness when a Residents or person move from a sitting to a standing position) was held and not administered on multiple occasions, on 2/16/2025, 2/20/2025, and 2/21/2025. Residents Affected - Few This failure resulted in Resident 1 not getting medication to treat his low blood pressure (BP) and potential return of symptoms to manage low blood pressure such as dizziness, lightheadedness, fainting spells, including decrease or limitation in Resident 1's activities of daily function, participation in his physical therapy treatment care, increased fall risk, injury and possible hospitalization. Findings: During a review of Resident's 1 Facesheet (FC), the FC indicated Resident 1 is [AGE] years old and was admitted to the facility in 2025. The FC indicated Resident 1's spouse is listed as emergency contact #1 and Resident as number 2. The FC also indicated Resident 1 had diagnosis of Injury at CS level of Cervical Spinal Cord (spinal cord in the neck region is damaged), Quadriplegia (partial or total loss of functions in all four limbs) , Hypotension (low blood pressure which can cause fainting or dizziness), Disorder of the Autonomic Nervous System (dysfunction of the nerves that regulate nonvoluntary body functions such as heart rate, BP), Muscle Weakness Generalized , and Depression. During a review of Resident 1's Minimum Data Set Record (MDS, a resident assessment tool use to guide care), dated 2/20/2025, the MDS indicated Resident 1 had a score of 15 on the Brief Interview for Mental Status exam. (BIMS, a scoring system used to determine the resident's cognitive status regarding attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status). During a review of Resident 1's Medication Administration Record (MAR), Midodrine was not administered or held on 2/16/2025, 2/20/2025, and 2/21/2025. Resident 1's MAR indicated, Schedule for [DATE], Midodrine HCL Oral 10 MG (milligram) . Give 2 tablet via G-Tube every 8 hours for hypotension . Hold for SBP (systolic blood pressure) > (greater) 140 . start date 2/4/2025 . Sun (Feb) 16 .2100 . BP (blood pressure) 140/80 . 2 (code) . Midodrine HCL Oral 10 MG . Give 1.5 tablet via G-Tube three times a day for hypotension . Hold for SBP > 140 . start date 2/18/2025 .Thu (Feb) 20 . 0800 . BP 140/62 . 2 (code) . Fri (Feb) 21 . 2000 . BP 140/90 . 2 (code) . Resident 1's MAR also indicated, Chart Codes / Follow Up Codes . 2 = No Med Required - Outside of Parameter . During a record review and an interview on 3/21/25 at 12:09 p.m., with Unit Supervisor (US), US stated the physician's order on the MAR indicated hold Midodrine medication for Systolic Blood Pressure (SBP) greater than 140, meaning if Resident 1's SBP was at 141, then the nurse or staff passing the medication will hold the medication, but when it was at 140, the staff should have given the medication. When asked for the reason Midodrine medication was held and not given, when Resident's 1 SBP was at 140, US stated it was the facility's expectation for Licensed Vocational Nurse (LVN) 2 to have notified the Physician. US also stated LVN 2 should have documented in Resident 1's progress notes that Midodrine HCL was not given and was held because BP did not meet physician order parameters. US 056327 Page 3 of 4 056327 04/17/2025 Walnut Creek Skilled Nursing & Rehabilitation Cent 1224 Rossmoor Parkway Walnut Creek, CA 94595

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated for Resident 1's Midodrine medication, facility nursing staff were trying to prevent from lowering Resident 1's BP, so if the medication was not given there is a possibility Resident 1's BP would have dropped. During an interview on 3/21/25 at 12:35 p.m., with the Administrator (ADM), ADM stated LVN 2 should have followed the physician's orders, which states on the MAR to hold for SBP greater than 140, because it's the physician's orders. During an interview on 4/22/25 at 6:36 p.m. with Resident 1, Resident 1 stated his Midodrine medication was never given the morning of 2/20/25. Resident 1 stated his primary charge nurse, LVN 1 did not come to his room in the morning of 2/20/2025 and that LVN 1 sent another nurse to help pass his medications. During an interview on 4/22/25 at 11:36 a.m. with listed Responsible Party (RP) on Resident 1's FC, RP stated Resident 1 is a paraplegic and unable to move both legs. RP stated Resident 1 wants to move and needed his medications in other to get physical therapy (PT). The RP stated she was at the facility and was in the room with Resident 1 all morning until the afternoon on 2/20/2025 when LVN 2 held and did not give Midodrine dose scheduled at 8:00 a.m. RP further stated Resident 1's primary nurse did not come into Resident 1's room and instead it was another nurse (LVN 2) who came to Resident 1's room. During an interview on 4/17/25 at 3:45 p.m., with LVN 1, LVN 1 stated she was very busy taking care of other residents on the morning of 2/20/25, and the desk nurse, LVN 2 had stepped in to help her. During an interview on 3/21/2025 at 12:42 p.m., with LVN 2, LVN 2 stated if she had held Resident 1's medication, the process is to have notified the physician the Midodrine was held and not given, in case there is any drug interaction with the upcoming medications due to be given to Resident 1. During a review of the facility's policy and procedure (P&P), titled, Administrating Medications dated 2001, the P&P indicated, Medication shall be administered in a safe and timely manner and as prescribed . 3. Medication must be administered in accordance with the orders, including any required time frame. 056327 Page 4 of 4