Health inspection·March 20, 2025

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility: Residents Affected - Few 1. Did not ensure prescribed medication for Resident 1 was available on the scheduled administration time on 3/18/25 at 4:00 PM, and 3/19/25 at 12:00 AM and 8:00AM. 2. Did not properly account for the receipt of the controlled medication (drugs or substances that are regulated by the government due to their potential for abuse and addiction) (diazepam- a controlled substance to treat anxiety, muscle spasms, and seizures) for Resident 1. These failures resulted in the potential for reduced effectiveness to prevent a worsening of symptoms or flare-ups of muscle spasms or increased physical discomfort related to complex regional pain syndrome or potentially leading to anxiety or mood swings. Improper accounting practices during the receipt of this controlled medication compromises the facility's ability to maintain adequate medication availability and meet the resident's needs. Findings: 1. During a concurrent interview and record review on 3/19/25 at 1:35 PM with the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN1) of Resident 1's medication administration record (MAR) dated March 1-31, 2025, was reviewed. MAR indicated , Valium (Diazepam) oral tablet 5mg give 1 tablet by mouth every 8 hours for muscle spasms related to complex regional pain syndrome, and the nursing/MAR notes dated 3/18/25 at 5:14 PM, 3/19/25 at 12:22 AM, 3/19/25 at 8:00AM, and 3/19/25 at 3:56 PM, were reviewed. Resident 1's March MAR and March 18-19, 2025 Nursing Notes indicated 3 doses (3/18/25 at 4:00 PM, 3/19/25 12:00 AM, and 3/19/25 at 8:00AM) of diazepam were not given. Both the ADON and LVN1 stated the resident's last dose of diazepam was given on 3/18/25 at 8:00 AM, and Resident 1 missed the next 3 doses due to no inventory. During an interview on 3/19/25 at 3:40 PM with LVN2, LVN2 stated the day nurse endorsed to him that there was no diazepam for Resident 1's 4:00 PM dose, and pharmacy had been called. LVN2 stated he notified the Family Nurse Practitioner (FNP) who was close by and he filled an order for 60 tabs which was faxed to pharmacy 3/18/25 at 3:50 PM. LVN2 stated he did not document a nursing note at the time he notified FNP of no supply, but when told by ADON to make a late entry of this, he complied. LVN2 admitted this was an error stating if it's not documented, it wasn't done, and I will do better next time. During an interview on 3/19/25 at 4:10 PM with Director of Nursing (DON), DON stated Resident 1 missed 3 doses of diazepam 5mg due to no supply. DON agreed facility did not ensure diazepam was Page 1 of 2 056394 056394 03/20/2025 Golden Pavilion Healthcare 99 Escuela Drive Daly City, CA 94015

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few available for this Resident and was not administered scheduled medication on time. DON agreed the facility Policy and Procedure (P/P) titled Administering Medications was not followed. During a review of Resident 1's Order Summary Report, dated 3/20/25, the Order Summary Report indicated diazepam oral tablet 5mg give 1 tablet by mouth every 8 hours for muscle spasms related to complex regional pain syndrome I. 2. During a concurrent interview and record review on 3/19/25 at 3:40 PM with LVN2, a faxed verification report dated 3/18/25 at 3:50 PM was reviewed. The verification report indicated that 60 tablets of diazepam 5mg were ordered for Resident 1 by the FNP. LVN2 stated FNP filled order for 60 tabs which was faxed to pharmacy 3/18/25 at 3:50 PM. During concurrent interview and record review on 3/19/25 at 4:00 PM with ADON, Manifest ID for rx#54009414 for Resident 1, dated 3/4/25 at 10:19 PM; Controlled Drug Record, dated 3/4/25, and LVN2's Nursing Note dated 3/19/25 at 8:53 PM were reviewed. The Manifest ID indicated that 90 tablets of diazepam 5mg for Resident 1 were delivered, and signed by LVN2. The Controlled Drug Record indicated 31 tabs of diazepam 5mg for Resident 1 was accepted on 3/8/25 at 8:00 AM. LVN2's Note indicated 42 tablets of diazepam were received from pharmacy today for the Resident. ADON stated there was a discrepancy of these documents. During a review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, medications are administered in a safe and timely manner, and as prescribed. The Controlled Medication Storage indicated under Procedures E (1 & 2)- any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies 056394 Page 2 of 2