Health inspection·January 31, 2025

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility had safe guards in place for their controlled drugs (a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) to prevent loss of and/or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled drugs in the facility for two of three sampled residents (Residents 1 and 2), by failing to: 1. Ensure Resident 1 ' s Oxycodone Hydrochloride [a narcotic (a drug that works in the brain to dull the sense of pain) to relieve moderate to severe pain] 5 milligrams ([mg] a unit of measurement) was double locked in the Director of Nursing ' s Office and/or medication cart (a moveable piece of equipment used in healthcare facilities to store, transport, and dispense medicines, medical supplies, and emergency equipment). 2. Ensure the medication refrigerator was locked containing Lorazepam (medication for treatment of anxiety- schedule IV drug) was stored in the refrigerator per the facility ' s policy and procedure (P&P) titled Storage of Medications. These failures had the potential for theft, loss, drug diversion, and unauthorized consumption of medications. Findings: a. During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including of fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain, fatigue, and other symptoms). During a review of Resident 1 ' s Nursing Progress Notes dated 1/15/2025, the Nursing Progress Notes indicated Resident 1 was alert and oriented. During a review of Resident 1 ' s Individual Resident ' s Narcotic Record dated 1/2025, the Individual Resident ' s Narcotic Record indicated Resident 1 had two tablets (home medication brought in by Resident 1 upon admission to the facility) of Oxycodone 5 mg accounted for. The Resident ' s Individual Narcotic Record indicated Resident 1 received one tablet of Oxycodone 5 mg on 1/15/2025 at 8:30 p.m. b. During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was admitted Page 1 of 2 056425 056425 01/31/2025 Studebaker Healthcare Center 13226 Studebaker Rd Norwalk, CA 90650

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some to the facility on [DATE] with diagnoses including of epilepsy (a brain disorder in which a person has repeated seizures [uncontrolled movement]). During a review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 1/17/2025, the MDS indicated Resident 2 ' s cognition was severely impaired and required substantial/maximal assistance (helper does more than half the effort) to complete Activities of Daily Living (ADLs – routine tasks/activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 2 ' s Physician Order dated 8/8/2024, the Physician Order indicated Lorazepam solution 1 mg to be given intramuscularly ([IM] into a muscle) every six hours as needed for seizure episode. During a concurrent observation and interview on 1/31/2025 at 9:50 a.m. with the DON, in the station 2 medication room, Resident 1 ' s bottle of Oxycodone 5 mg was found in an unlocked drawer. The bottle of Oxycodone 5 mg was observed containing 1 tablet. The medication refrigerator ' s padlock (a portable or detachable lock) was observed lying on the top of the refrigerator. The DON stated the Resident 2 ' s Lorazepam should be locked in the medication refrigerator. During an interview on 1/31/2025 at 9:51 a.m. and subsequent interview at 1:45 p.m., the DON stated facility staff reported to her that Resident 1 had a bottle of Oxycodone in her purse when she was admitted and the bottle had two pills in the bottle. The DON stated the bottle of Oxycodone was stored in an unlocked drawer in the Station 2 medication room. The DON stated the Lorazepam solution should be locked in the refrigerator, and she could not provide an answer regarding what would happen to the Lorazepam solution if not properly secured. During a review of the facility ' s policy and procedure (P&P) titled Storage of Medications, dated 12/2023, the P&P indicated controlled medications scheduled II, III, IV are designated as such by a red controlled drug stamp and count sheet and are subject to special storage requirements. The P&P indicated the controlled medications must be stored in a double locked storage compartment except when given as regularly scheduled medications and part of the cycle medications (Schedule III and IV only). The P&P indicated schedule II medications must be double locked. 056425 Page 2 of 2