Health inspection·April 29, 2025

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents were free of medication errors when one of three sampled residents (Resident 3) was not given the correct dosage of a medication, Uptravi (generic name selexipag) a medication used to treat pulmonary hypertension (high blood pressure in the arteries that carry blood from the heart to the lungs). This failure had the potential for Resident 3 to have a drug overdose causing physical problems ranging from pain, rashes, weakness, organ failure, (when organs in the body such as the heart, lungs, kidneys or liver are unable to perform their critical functions), seizures or even death. Residents Affected - Some Findings: During an interview on [DATE] at 11:55 a.m., Family member of Resident 3 (Family) complained that Resident 3 was given the wrong dose of her medication several times. Family stated they gave the facility a month supply of her medication from home because the medication was not available at all pharmacies. Family stated, I found out that my wife had been getting 4 pills per dose when it should have been 1 pill per dose when the nurse asked for a refill. Family complained We should not be out of the medication, how did it run out, can ' t the nurses read the label! Family stated they were giving her one tablet of Uptravi 800 mcg (microgram, one millionth of a gram) 2 times a day at home. During a record review on [DATE] Resident 3 ' s admission Record (form to show key facts about resident) indicated Resident 3 was admitted on [DATE] and had Diagnosis of End Stage Kidney disease, Diabetes, and Pulmonary Hypertension (HTN.) During a record review on [DATE] Resident 3 ' s Order Summary Report (Doctors orders) the medications for Resident 3 were documented. The order for Uptravi read: Uptravi oral tablet 200 mcg (Selexipag) give 4 tablets by mouth two times a day for Pulmonary HTN (800 mcg). This medication is filled by an outside specialty pharmacy. Start date [DATE]. Four tablets of 200 mcg would equal 800 mcg, which is the desired dosage. During a record review on [DATE] Resident 3 ' s Medication Administration Record (MAR) for [DATE] included Uptravi oral tablet 200 mcg (Selexipag) give 4 tablets by mouth two times a day for Pulmonary HTN (800 mcg). This medication is filled by an outside specialty pharmacy. Start date [DATE]. Nursing had administrated the medication 29 times over 15 days based on the initialing on the MAR indicating a dose was given. The MAR did not have any documentation to indicate that a nurse gave one 800mcg tablet in place of the four 200mcg tablets to be given per the doctor ' s order. During an interview and concurrent observation on [DATE] at 12:25 p.m., Licensed Staff A opened the medication cart to look at the medication bottle. The medication bottle was no longer in the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 056411 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056411 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Park View Post Acute 3751 Montgomery Dr Santa Rosa, CA 95405 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)