Health inspection·August 14, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide services which met professional standards of practice for two of the five sampled residents (Resident 1, and Resident 5) when Resident 1 and Resident 5's medications were not available, and the license nurse did not notify the physician the medications were not administered. This failure had the potential risk for Resident 1 and Resident 5 to experience worsening of existing health conditions and delayed medical response. During a record review on 8/7/25 at 11:47 a.m. with the Licensed Vocational Nurse (LVN) at the nurses' station, Resident 1's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/7/25 was reviewed. The AR indicated Resident 1 was admitted [DATE] with diagnoses of left knee osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time), asthma (a chronic lung disease caused by inflammation and muscle tightening around the airways making it hard to breathe), hypertensive heart disease (problems with your heart that can develop if you have high blood pressure), hypothyroidism (thyroid gland doesn't make enough thyroid hormone), attention-deficit (not being able to keep focus), hyperactivity (excess movement that is not fitting to the setting) disorder, hyperlipidemia (high cholesterol), major depressive disorder (persistent feeling of sadness and loss of interest), anxiety (differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety) disorder and dry eye syndrome. During a concurrent interview and record review on 8/7/25 at 11:50 a.m. with the LVN, Resident 1's MAR dated 7/2025 was reviewed. The MAR indicated the Gabapentin (medication used to treat epilepsy [a brain condition that causes abnormal brain electrical activities]) 600 milligrams (mg-unit of measurements) tablet - give 2 tablets by mouth at bedtime for pain, Nortriptyline Hydrochloride (medication used to treat depression and its commonly prescribed for various pain) 10 mg capsule- give 10 mg by mouth at bedtime for depression, Sertraline Hydrochloride (medication used to treat depression and panic disorder) 100 mg tablet - give 100 mg by mouth at bedtime for depression and Icosapent ethyl (omega-3 fatty acids) 1gm capsule-give 1 capsule by mouth two times a day for HLD (hyperlipidemia-abnormal high levels of fats), all scheduled to start on 7/10/25, were not administered due to pending pharmacy delivery. The LVN stated when medications are unavailable and not given, the licensed nurse (LN) should have notified the physician so the physician could decide whether Resident 1 can skip the dose, needs an alternative medication, or should go to the hospital. The LVN stated she could not find any documentation the LN notified the provider. The LVN stated failure to follow the facility's unavailable medication procedure could put Resident 1 at risk for worsening chronic conditions. During a review of Resident 5's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/7/25, the AR indicated Resident 5 was admitted to the facility on [DATE] with diagnoses: right knee effusion (fluids in the tissues around your joint causing swelling), right knee arthritis (joint Residents Affected - Few Page 1 of 2 056338 056338 08/14/2025 Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few inflammation), anxiety disorder(differ from normal feelings of nervousness or anxiousness and involve excessive fear or anxiety), irritable bowel syndrome (a common condition characterized by abdominal discomfort associated with altered bowel movements), and pain. During a review of Resident 5's MAR dated July 2025, the MAR indicated 7/19/25 Brimonidine Tartrate Ophthalmic Solution 0.2% (medication used to lower eye pressure by reducing fluid production in the eye) instill 1 drop in both eyes two times a day for eye lubricant at 18:00 [6 p.m.].Latanoprost Solution 0.0005% (medication used to lower eye pressure by increasing fluid outflow from the eye) instill 1 drop in both eyes at bedtime for eye lubricant at 20:00 [8 p.m.]. were held. During a review of Resident 5's Progress Note dated 7/19/25 indicated Brimonidine Tartrate Ophthalmic Solution and Latanoprost Solution 0.005% were pending delivery. During an interview on 8/7/25 at 2:37 p.m. with the Registered Nurse (RN), the RN stated when medications were not available, the LN would call the pharmacy to find out when the medications would be delivered. The RN stated if medications were not given, the LN would document in the MAR and progress note. The RN stated if medications ordered were new and the facility was awaiting pharmacy to deliver the medications; the LN did not need to notify the physician. During an interview on 8/14/25 at 3:15 p.m. with the Director of Nursing (DON), the DON stated the LN should have notified the physician when medications are unavailable and not given. The DON stated the nurse should have called the physician to report the medications were not available so the physician could decide if an alternative medication was needed. The DON stated the LN placed the residents at risk for worsening chronic health conditions by not reporting to the physician the medications were not given. The DON stated notifying the physician of medications not available and not given was standard practice. During a review of the facility's policy and procedure (P&P) titled, 7.0 Medication Shortages/Unavailable Medications, dated 8/01/24, the P&P indicated 5. If the medication is unavailable from Pharmacy or third-party Pharmacy, and cannot be supplied from the manufacturer, facility should obtain alternate Physician/Prescriber orders, as necessary. 6. If the medication is unavailable from the Pharmacy.Facility should collaborate with Pharmacy and Physician/Prescriber to determine a suitable therapeutic alternative. 7. If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact Facility's Medical Director for alternate orders/directions, making sure to explain the circumstances of the medication shortage.9. When a missed does is unavoidable, Facility nurse should document the missed dose, and the explanation for such missed dose, on the MAR (Medication Administration Record) or TAR (Treatment Administration Record) and the nurse's notes per Facility policy.During a review of the National Library of Medicine Professional Referenced titled, Nursing Rights of Medication Administration, published 4/4/23, (found at https://www.ncbi.nlm.nih.gov/books/NBK560654/) the reference indicated, .Right time-administering medications at a time that was intended by the prescriber.A guiding principle of this ‘right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability of other chemical mechanisms. 056338 Page 2 of 2