Health inspection·March 12, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for two of two sampled residents (Residents 1 and 2) when Residents 1 and 2's controlled drug records and MARs were not maintained to ensure the accuracy reconciliation of the narcotic pain medications. * Resident 1's oxycodone HCl (narcotic pain medication) Individual Drug Record sheet did not match Resident 1's MAR. The oxycodone HCL was removed from the bubble pack for several occasions without documentation of the medication administration in the MAR. * Resident 2's hydrocodone-acetaminophen (narcotic pain medication) Individual Drug Record sheet did not match Resident 2's MAR. The hydrocodone-acetaminophen medication was removed from the bubble pack for several occasions without documentation of the medication administration in the MAR. These failures posed the for risk of diversion of the controlled medications. Findings: According to the facility's P&P titled Preparation and General Guidelines for Controlled Medications dated 8/2014 showed when a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): a. Date and time of administration; b. Amount administered; c. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply; and d. Initials of the nurse administering the dose on the MAR after the medication is administered. 1. Review of Resident 1's medical record was initiated on 3/7/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report dated 1/30/24, showed a physician's order dated 12/29/23, to administer oxycodone HCl 10 mg by mouth every four hours as needed for severe pain. Page 1 of 3 056362 056362 03/12/2024 Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

F 0755 Level of Harm - Minimal harm or potential for actual harm Review of Resident 1'sIndividual Narcotic Record sheet for oxycodone HCl 10 mg one tablet by mouth every four hours as needed for severe pain received 12/30/23, showed one tablet of oxycodone HCl was removed from the medication bubble pack on the following dates and times: - 12/30/23 at 2240 hours; Residents Affected - Few - 12/31/23 at 0140 and 0540 hours; -1/1/24 at 2200 hours; - 1/2/24 at 0200 and 0600 hours; - 1/4/24 at 1200 hours; - 1/5/24 at 1200 hours; - 1/6/24 at 0900 hours; - 1/8/24 at 2030 hours; - 1/9/24 at 0030 hours; and - 1/10/24 at 0700 and 1100 hours. However, review of Resident 1's December 2023 and January 2024 MARs failed to show documentation of the above oxycodone HCl medication administration when it was taken out of the medication bubble pack. On 3/12/24 at 1115 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 stated when the resident requested for the pain medication, the LVN assessed for the resident's pain levels and locations. LVN 1 further stated he would remove the medication from the bubble pack, sign out the medication in the narcotic record sheet, administer the medication, and document in the MAR. LVN 1 stated he was assigned to care for Resident 1 on 12/31/23, 1/4, 1/4, 1/6, 1/9, and 1/10/24. LVN 1 verified and acknowledged he did not document the oxycodone HCl medication administration in Resident 1's MAR. On 3/12/24 at 1516 hours, a concurrent interview and medical record review was conducted with LVN 2. LVN 2 stated she was assigned to care for Resident 1 on 12/30, 12/31/23, 1/1, 1/2, and 1/8/24. LVN 2 verified and acknowledged she signed off the oxycodone HCl medication from the narcotic record but did not document in Resident 1's MAR. 2. Closed medical record review of Resident 2 was initiated on 3/7/24. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 12/27/23, showed a physician's order dated 11/15/23, to administer hydrocodone-acetaminophen 10-325 mg one tablet by mouth every four hours as needed for moderate pain; and two tablets by mouth every four hours as needed for severe pain. Review of Resident 2's Individual Narcotic Record sheet received on 12/22and 12/30/23, for 056362 Page 2 of 3 056362 03/12/2024 Mesa Verde Post Acute Care Center 661 Center Street Costa Mesa, CA 92627

F 0755 hydrocodone-acetaminophen 10-325 mg medication showed one tablet of hydrocodone-acetaminophen 10-325 mg was removed from the medication bubble pack on the following dates and times: Level of Harm - Minimal harm or potential for actual harm - 12/29/23 at 0900 hours; Residents Affected - Few -12/30/23 at 0900 and 2300 hours; - 12/31/23 at 0300, 0700, 1100, and 1500 hours; -1/2/24 at 0200, 0600 hours; - 1/4/24 at 0900, 1400 hours; - 1/5/24 at 0900 hours; - 1/6/24 at 1200 hours; - 1/7/24 at 1520 hours; - 1/8/24 at 1439 and 2315 hours; and - 1/10, 1/11, and 1/12/24 at 0900 hours. However, review of Resident 2's December 2023 and January 2024 MARs failed to show the documentation of the above hydrocodone-acetaminophen medication administration when it was taken out of the medication bubble pack. On 3/12/24 at 1115 hours, a concurrent interview and closed medical record review was conducted with LVN 1. LVN 1 stated he was assigned to care for Resident 2 from 12/29/23 to 12/31/23, 1/4/24 to 1/6/24, and 1/10/24 to 1/12/24. LVN 1 verified and acknowledged he did not document the hydrocodone-acetaminophen medication administration in Resident 2's MAR. On 3/12/24 at 1516 hours, a concurrent interview and closed medical record review was conducted with LVN 2. LVN 2 stated she was assigned to care for Resident 2 on 12/31/23, 1/2/24, and 1/8/24. LVN 2 verified and acknowledged she signed off the hydrocodone-acetaminophen medications in the narcotic record sheet but did not document in Resident 2's MAR. On 3/12/22 at 1042, and 1605 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged and verified the above findings. The DON stated after administering the narcotic medications to the resident, the nurses should sign the resident's MAR. 056362 Page 3 of 3