Health inspection·June 27, 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 and record review, the facility failed to administer medications timely for one of three sampled residents (Resident 1), when multiple medications for Resident 1 were administered after the ordered administration time. This failure had the potential for exacerbating Resident 1's health condition and compromising their overall health and well-being. Findings: A record review of Resident 1 ' s Face Sheet, (undated), indicated Resident 1 was re-admitted to the facility on [DATE] with primary diagnoses including Human Immunodeficiency Virus (HIV, a virus that attacks cells that help the body fight infection, making a person more vulnerable to other infections and diseases), Chronic Obstructive Pulmonary Disease (COPD, refers to a group of diseases that cause airflow blockage and breathing-related problems. It includes emphysema and chronic bronchitis), End-Stage Renal Disease (ESRD, the final stage of long-term kidney disease when the kidneys are no longer sufficiently able to remove waste products and excess water to support the body ' s needs), Essential (primary) Hypertension (HTN, high blood pressure that is multi-factorial and doesn't have one distinct cause), Hyperlipidemia (an abnormally high concentration of or lipids in the blood), Clostridium Difficile (C-diff, a bacterium that can cause diarrhea and colitis, an inflammation of the colon. Infections can range from asymptomatic to life-threatening, and are the leading cause of diarrhea associated with antibiotics). A record review of Resident 1 ' s Minimum Data Set (MDS, a tool for assessing the health status of residents in long-term care nursing facilities that are certified to participate in Medicare or Medicaid), dated 5/21/24, indicated a Brief Interview for Mental Status (BIMS, is a scoring system used to determine the resident ' s cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status) could not be assessed for Resident 1, and a staff assessment of mental status was conducted. The facility found Resident 1 had a short-term memory problem, and Resident 1 was moderately impaired in making decisions regarding tasks of daily life. During a record review of Resident 1 ' s Physician Order Report dated 6/1/24 - 6/11/24, the following prescribed medications included: 1. Amlodipine 5 mg (milligram-a unit of measurement) tablet, oral, one time daily at 9:00 a.m. for hypertension, start 5/23/24 - open ended. Page 1 of 4 056389 056389 06/27/2024 Vale Healthcare Center 13484 San Pablo Avenue San Pablo, CA 94806

F 0755 2. Biktarvy 30-120-15 mg tablet, oral, once a day at 9:00 a.m. for HIV, start 5/23/24 - open ended. Level of Harm - Minimal harm or potential for actual harm 3. Clopidogrel 75 mg tablet, oral, once a day at 9:00 a.m. for cardiovascular prophylaxis (refers to preventing heart attack and stroke through drug therapy for high risk individuals), start 5/23/24 - open ended. Residents Affected - Few 4. Metronidazole 500 mg tablet, oral, every 8 hours at 12:00 a.m., 8:00 a.m., 4:00 p.m. for C-diff, start 5/17/24 - 6/1/24. 5. Sevelamer HCI 800 mg tablet, oral with meals (7:15 a.m. - 8:15 a.m., 12:00 p.m. - 1:00 p.m., 5:30 p.m. -6:30 p.m.) for ESRD, start 5/23/24 - open ended. A record review of Resident 1 ' s Medication Administration History dated 5/1/24 through 5/31/24 and 6/1/24 through 6/27/24 indicated: Amlodipine was administered 21 to 176 minutes late on the following dates: 10:24 a.m. on 5/30/24 10:21 a.m. on 6/4/24 10:52 a.m. on 6/8/24 10:32 a.m. on 6/9/24 1:16 p.m. on 6/15/24 Biktarvy was administered 24 to 176 minutes late on the following dates: 10:24 a.m. on 5/30/24 10:21 a.m. on 6/4/24 10:52 a.m. on 6/8/24 10:32 a.m. on 6/9/24 1:16 p.m. on 6/15/24 Clipidogrel was administered at 21 to 52 minutes late on the following date: 10:24 a.m. on 5/30/24 10:21 a.m. on 6/4/24 10:52 a.m. on 6/8/24 10:32 a.m. on 6/9/24 056389 Page 2 of 4 056389 06/27/2024 Vale Healthcare Center 13484 San Pablo Avenue San Pablo, CA 94806

F 0755 Metronidazole was administered 75 to 144 minutes late on the following dates: Level of Harm - Minimal harm or potential for actual harm 5:45 p.m. on 5/19/24 5:46 p.m. on 5/23/24 Residents Affected - Few 9:49 a.m. on 5/26/24 5:18 p.m. on 5/26/24 9:55 a.m. on 5/28/24 5:21 p.m. on 5/28/24 10:24 a.m. on 5/30/24 9:15 a.m. on 6/1/24 Sevelamer HCI was administered 67 minutes to 326 minutes late on the following dates: 10:21 a.m. on 6/4/24 9:27 a.m. on 6/6/24 8:03 p.m. on 6/6/24 10:52 a.m. on 6/8/24 10:32 a.m. on 6/9/24 1:41 p.m. on 6/9/24 (breakfast dose) 10:14 a.m. on 6/20/24 10:06 a.m. on 6/27/24 During an interview on 6/12/24, at 1:24 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 indicated she was rushed at times, and could not complete her medication pass on time. LVN 1 stated she was a registry nurse and was sometimes unfamiliar with residents. During an interview on 6/14/24, at 2:54 p.m., with Resident 1 ' s family member representative, the family member representative stated that it concerned her greatly that Resident 1 was always receiving medications late, and it made her worried about Resident 1 ' s overall health and well-being. During an interview on 6/27/24, at 11:48 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she was sometimes too busy to document at the time of medication administration, and documented it much later. LVN 2 stated she was aware this practice could cause errors, such as a resident receiving two doses of ordered medications. LVN 2 stated she ideally should document when residents have taken medications immediately after administration in the electronic medical health record. 056389 Page 3 of 4 056389 06/27/2024 Vale Healthcare Center 13484 San Pablo Avenue San Pablo, CA 94806

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/27/24, at 1:00 p.m., with the Assistant Director of Nursing (ADON), the ADON acknowledged appropriate standard of practice required time and date of medication administration should be recorded in resident charts immediately. During a record review of the facility ' s policy and procedure (P & P) titled, Medication Pass Guidelines, undated, indicated, Procedure: 6. Administer medications within 60 minutes of the scheduled time .for example, if the medication is ordered for 8:00 a.m., it must be given between 7:00 a.m. and 9:00 a.m. in ordered to be considered timely .Documentation: 1. Record the name, dose, route and time of medication on the Medication Administration Record .2.Use the electronic health record system where appropriate to complete the aforementioned documentation. 3. If the electronic record system is down, document on paper. 056389 Page 4 of 4