Health inspection·June 27, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure clinical records for one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards by failing to accurately document the administration of Resident 1's Oxycodone Hydrocholoride (a medication used to treat moderate to severe pain) on the Medication Administration Record (MAR- a report that serves as a legal record of the medications administered to a resident). This deficient practice placed Resident 1 at risk for medication errors, delayed pain relief and the potential for diversion (refers to redirection of prescription drugs from their intended use or disposal to unauthorized purposes) of a narcotic (a substance that dulled the senses and relieved pain) medication. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included fracture (broken bone) of lower end of right femur (thigh bone), type 2 diabetes (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), end stage renal disease (ESRD- irreversible kidney failure) and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 6/18/2025, the MDS indicated Resident 1's cognition (ability to think and make decisions) was intact. The MDS further indicated that Resident 1 required set-up assistance from staff with eating, oral hygiene and personal hygiene. The MDS indicated Resident 1 required maximum assistance from staff with toileting hygiene, showering, lower body dressing and putting on/taking off footwear. During a review of Resident 1's History and Physical (H&P) dated 6/13/2025, the H&P indicated Resident 1 has decision-making capacity. During a review of Resident 1's Physician Order Summary dated 6/12/2025, the Physician Order Summary indicated to give Oxycodone Hydrochloride oral tablet 10 milligrams (mg- unit of measurement), one tablet by mouth every four hours as needed for moderate to severe pain. During a review of Resident 1's Controlled Drug Record (refers to a detailed log or documentation system used to track the receipt, distribution, administration and disposal of controlled substances [refers to a medication or drug that is regulated by the government due to its potential for abuse or addiction]) dated 6/13/2025, the Controlled Drug Record indicated that Oxycodone Hydrochloride was Page 1 of 2 056363 056363 06/27/2025 Grand Valley Health Care Center 13524 Sherman Way Van Nuys, CA 91405

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few signed out for administration to Resident 1 by Licensed Vocational Nurse (LVN) 1 on 6/13/2025 at 9:30 p.m. and LVN 2 on 6/14/2025 at 11:00 a.m. During a review of Resident 1's MAR, dated 6/2025, the MAR did not indicate Oxycodone Hydrocholoride was administered for the doses signed out in the Controlled Drug Record on 6/13/2025 at 9:30 p.m. and 6/14/2025 at 11:00 a.m. During an interview on 6/27/2025 at 2:30 p.m., with the Director of Nursing (DON), the DON stated that when nursing staff administer medication to a resident, it should be documented on the MAR to reflect the administration of the medication and align with the corresponding entries in the Controlled Drug Record. The DON stated that the Oxycodone Hydrochloride signed out for Resident 1 on 6/13/2025 at 9:30 p.m. and 6/14/2025 at 11:00 a.m. should have been documented on Resident 1's MAR to indicate that it was administered. During a review of the facility's policy and procedure (P&P) titled Medication Administration-General Guidelines dated 8/15/2024, the P&P indicated medications are administered only by licensed nursing, medical, pharmacy or other personal authorized by state laws and regulations to administer medication. Medications are administered in accordance with written orders of the attending physician .The individual who administers the medication dose records the administration on the residents MAR directly after mediation is given. At the end of reach medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. 056363 Page 2 of 2