Other·September 22, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an ABBREVIATED SURVEY to investigate a Complaint and Entity Reported Incident No: CA00543106. Inspection was limited to the specific Complaint and Entity Reported Incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: Surveyors 37663, HFEN; 36872, HFEN; and 38868, HFEN. THE DEPARTMENT SUBSTANTIATED THE COMPLAINT AND ENTITY REPORTED INCIDENT ALLEGATION(S) AND FINDINGS WERE CITED AT F333 and F431. GLOSSARY OF ABBREVIATIONS AND BRIEF DEFINITIONS DON - Director of Nursing EMS - Emergency Medical Service ER - extended release Hypercapnia - presence of excess of carbon dioxide in the blood Hypoxia - a dangerous condition that happens when your body doesn't get enough oxygen IM - intramuscular LVN - Licensed Vocational Nurse MAR - Medication Administration Record mg - milligram(s) Opiod - narcotics medication that contain opium Oxygen saturation - amount of oxygen in the blood PCO2 - partial pressure of carbon dioxide LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 1 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (carbon dioxide concentration in the arterial blood) Pulmonary ventilation - the process of exchange of air between the lungs and the ambient air P&P - policy and procedure RN - Registered Nurse

F333 SS=D RESIDENTS FREE OF SIGNIFICANT MED ERRORS CFR(s): 483.45(f)(2)

F333 483.45(f) Medication Errors. The facility must ensure that its(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and medical record review, the facility failed to ensure one of the two sampled residents (Resident 1) was free from a significant medication error. LVN 3 administered another resident's (Resident A) morphine sulfate (narcotic pain medicine) 60 mg ER and Synthroid 150 mcg to Resident 1. This resulted in Resident 1 experiencing extreme drowsiness and low oxygen saturation levels, requiring her to be transferred and subsequently admitted to the acute care hospital. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 2 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: According to Lexicomp online, a pharmacy resource used by healthcare professionals, morphine sulfate ER should be swallowed intact and should not be broken, crushed, or chewed. Administration of a broken or crushed tablet may result in too rapid a release of the drug from the preparation and absorption of a potentially toxic dose of morphine sulfate. Cutting, breaking, crushing, chewing, or dissolving ER formulations may result in uncontrolled delivery of morphine, leading to overdose, and death. The mixture of applesauce or pellets should not stored for future use. Warning for respiratory depression, the major toxicity associated with morphine occurs most frequently in geriatric and debilitated patients, and those with conditions accompanied by hypoxia (a dangerous condition that happens when your body doesn't get enough oxygen) or hypercapnia (presence of excess carbon dioxide in the blood) when even moderate therapeutic doses may dangerously decrease pulmonary ventilation (the process of exchange of air between the lungs and the ambient air). May be severe, requiring maintenance of an adequate airway, use of resuscitative equipment, and administration of oxygen, an opiate antagonist (drugs that block the effect of opioids), and/or other resuscitative drugs. Medical record review for Resident 1 was initiated on 7/14/17. Resident 1 was admitted to the facility on 1/12/14, and readmitted on 7/13/17. Review of the MDS dated 6/12/17, showed Resident 1 was cognitively impaired and not able to make her needs known. Resident 1 was identified to be totally dependent on staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 3 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for all care needs. Review of a Progress Note dated 7/7/17, showed an investigation was conducted regarding a medication error. Resident 1 was administered morphine sulfate 60 mg ER which had been dissolved in apple sauce. Documentation showed Resident 1 was administered morphine sulfate 60 mg ER at approximately 0630 hours on 7/6/17. Resident 1 was identified by the oncoming 7am-7pm shift staff to have a change of condition; Resident 1 had a decreased level of consciousness, was not responsive, and had a drop in her oxygen saturation (77% on room air), requiring the administration of oxygen. At approximately 0800 hours, the 911 paramedic team was called. The paramedics arrived and transported Resident 1 to the acute care hospital emergency department at approximately 0815 hours. Review of Resident 1's medication orders showed no order for morphine sulfate. Review of the physician's order dated 7/6/17 at 0740 hours, showed to send Resident 1 to the acute care hospital emergency department for evaluation. Review of the Nursing Home to Hospital Transfer form dated 7/6/17, showed Resident 1 was sent to the acute care hospital due to being lethargic, altered level of consciousness, and low respiratory rate. The Nursing Home to Hospital Transfer form showed Resident 1 was administered morphine sulfate 60 mg ER at 0630 hours, which was intended for another resident. Review of the acute care hospital's medical record dated 7/6/17, showed Resident 1's admitting diagnoses including opiate overdose. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 4 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The emergency department documentation identified Resident 1 was inadvertently given morphine sulfate 60 mg at the nursing home facility. The Emergency Department Report dated 7/6/17 at 0911 hours, showed the Emergency Medical Service (911 paramedic team) administered Narcan (opioid antidote - a reversal agent) 2 mg IM injection at 0812 hours. Review of Resident 1's laboratory tests dated 7/6/17, showed the PCO2 was 50 (normal level: 35-45) while Resident 1 was being administered two liters of oxygen. The toxicology results showed Resident 1's urine was positive for opiate drug. The physician's progress note showed Resident 1 became somnolent (drowsy) and required a Narcan drip. Resident 1 was admitted to the Coronary Intensive Care Unit for frequent reassessment and monitoring. Resident 1 was readmitted to the facility on 7/13/17. Review of the Patient and Transfer Referral Record from the acute care hospital dated 7/13/17, showed Resident 1 was transferred back to the skilled nursing facility after seven days with a primary diagnosis of opioid overdose. Review of the facility's Medication Error Report dated 7/6/17, showed Resident 1 was accidentally given morphine sulfate 60 mg ER, intended for another resident (Resident A). Due to the medication error, Resident 1 became lethargic but arousable; the oxygen saturation level was 77% (normal range: 95100%), the respiratory rate was 14 respirations per minute, the heart rate was 114 bpm, and the blood pressure was 112/58 mmHg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 5 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 7/14/17 at 0925 hours, an interview and concurrent facility document review was conducted with the DON. The DON was asked about the Medication Error Report for Resident 1 dated 7/6/17. The DON confirmed LVN 3 administered Resident A's morphine sulfate 60 mg ER to Resident 1. On 7/14/17 at 1625 hours, an interview was conducted with RN 1. RN 1 was asked about the medication error report for Resident 1. RN 1 stated LVN 4 asked her to assess Resident 1 who was lethargic and wearing an oxygen cannula, which was unusual for Resident 1. On 7/17/17 at 1205 hours, a telephone interview was conducted with LVN 3. LVN 3 was asked about the medication error for Resident 1. LVN 3 stated she crushed Resident A's Synthroid 150 mcg tablet and put the morphine sulfate 60 mg ER tablet in the same medication cup with apple sauce and the tablets "melted in there." LVN 3 stated Resident A refused the medications. LVN 3 stated she placed the medication cup in the medication cart drawer but did not label the medication cup with Resident A's name. LVN 3 stated she planned to offer Resident A her morphine sulfate and Synthroid a second time a little later. She said the facility's policy was to offer the refused medications three times. LVN 3 stated she crushed Resident 1's Synthroid 50 mcg tablet and placed it in a medication cup and added apple sauce to help dissolve it. However, Resident 1 was asleep so she placed Resident 1's medication cup in the medication cart drawer. LVN 3 stated she did not label the medicine cup with Resident 1's name. LVN 3 stated a CNA got Resident 1 up in her gerichair and placed her by the nurses' station and that was when she noticed Resident 1 was snoring and very sleepy, which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 6 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was not normal for her. LVN 3 stated that was when she realized she might have accidentally administered Resident A's medications to Resident 1. LVN 3 stated she took Resident 1's blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation level. LVN 3 stated she informed LVN 4 and Resident 1's attending physician who was at the facility at that time. Resident 1's attending physician initially instructed LVN 3 to monitor Resident 1's vital signs. LVN 3 stated she informed RN 2 she had accidentally administered morphine sulfate 60 mg ER, the wrong medication, to Resident 1 and asked RN 2 to assess Resident 1. LVN 3 stated Resident 1's attending physician called the nursing unit a few minutes later and ordered to transfer Resident 1 to the acute care hospital emergency department for evaluation. On 7/17/17 at 1650 hours, a telephone interview was conducted with RN 2. RN 2 stated on the morning of 7/6/17, Resident A refused the morphine sulfate 60 mg ER and LVN 3 accidentally administered the morphine sulfate 60 mg ER to Resident 1. RN 2 stated he assessed Resident 1 with RN 1 and LVN 3. Resident 1 was lethargic, but her eyes would open when her name was called. They called 911 and the paramedics transported Resident 1 to the acute care hospital emergency department.

F431 SS=D DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 The facility must provide routine and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 7 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 8 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on interview, medical record review, and facility P&P review, the facility failed to ensure proper storage and disposal of two residents' medications (Residents 1 and A). LVN 3 failed to dispose of Resident A's refused morphine sulfate (narcotic medication) 60 mg ER and Synthroid 150 mcg. This resulted in LVN 3 administering morphine sulfate and Synthroid to Resident 1 in error, causing serious adverse effects to Resident 1 who was required to be transferred to the acute hospital emergency department. Findings: Review of the facility's P&P titled Disposal or Destruction of Expired or Discontinued Medication revised 7/18/17, showed wasted medications include the refused medications that require disposal. The facility's policy showed the staff should not place the wasted medications back in their original containers, and the controlled medications (such as morphine) should be destroyed by two licensed nurses. This procedure applies to the disposal of unused doses (whole tablets, partial tablets, unused portions of single dose ampules and doses of controlled substances) wasted for any reason. On 7/14/17 at 1220 hours, an interview was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 9 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE conducted with LVN 1. LVN 1 was asked what the process was when a resident declined to take a medication that had been prepared to be administered. LVN 1 stated he would label the cup with the resident's name and room number and lock the medications in the medication cart. LVN 1 stated he would offer the medication to the resident two to three times within a 15 to 30 minutes interval. On 7/14/17 at 1340 hours, an interview was conducted with LVN 2. LVN 2 was asked what the process was when a resident declined to take their prepared medications. LVN 2 stated she would lock the medications in the top drawer of the medication cart. LVN 2 stated when more than one resident declined their medications, she would dispose of the medications. On 7/14/17 at 1520 hours, an interview was conducted with the DON. The DON was asked what the process was when a resident declined to take their prepared medications. The DON stated the Administration of Medication P&P was not specific on resident's refusal of medications. The DON stated the medications would be discarded or disposed of. Review of a Medication Error Report dated 7/6/17, showed there was a medication error involving Resident 1. Resident 1 was administered Resident A's morphine sulfate 60 mg and Synthroid 150 mcg. Medical record review for Resident 1 was initiated on 7/14/17. Resident 1 was admitted to the facility on 1/12/14, and readmitted on 7/13/17. Review of the MDS dated 6/12/17, showed Resident 1 was cognitively impaired and not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 10 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE able to make her needs known. Resident 1 was identified to be totally dependent on staff for all care needs. Review of Resident 1's physician's orders showed an order to administer Synthroid 50 mcg. There was no order for morphine sulfate 60 mg and Synthroid 150 mcg. On 7/17/17 at 1205 hours, a telephone interview was conducted with LVN 3. LVN 3 stated she crushed Resident A's Synthroid 150 mcg tablet in a medication cup with apple sauce. She then placed Resident A's morphine sulfate 60 mg ER tablet in the same medication cup. LVN 3 stated when she went to offer Resident A her medications, Resident A refused to take them. LVN 3 stated she placed the prepared medication cup containing those two medications and locked them in the medication cart in the top drawer. LVN 3 stated she did not label the medication cup with Resident A's name or room number. LVN 3 stated she had prepared to administer Resident 1's medication (Synthroid 50 mcg), but Resident 1 was asleep so she placed Resident 1's medication cup in the medication cart top drawer. She stated she did not label the medication cup with Resident 1's name or room number. LVN 3 stated when she did administer Resident 1's medication, she inadvertently administered Resident A's medications to Resident 1. On 7/17/17 at 1650 hours, a telephone interview was conducted with RN 2. RN 2 was asked what the process was when a resident refused to take the prepared narcotic medications. RN 2 stated he would not discard the narcotic medication when the resident first refused but would lock the medication in the medication cart and label it with the resident's name. RN 2 stated he would offer the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 11 of 12 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555308 (X3) DATE SURVEY COMPLETED 08/09/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE TRABUCO HILLS POST ACUTE 25652 Old Trabuco Rd Lake Forest, CA 92630 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE medication again after a few minutes. RN 2 stated he was not sure of the facility's policy was. On 7/19/17 at 1110 hours, a telephone interview was conducted with the facility's Pharmacy Consultant. The Pharmacy Consultant was asked what the policy or process was when a resident refused the prepared narcotic medication. The Pharmacy Consultant stated the nurse should document on the back of the resident's MAR when the resident refused the medications. The Pharmacy Consultant stated when a resident refused a narcotic medication, the medication would be disposed of. The refused narcotic medication should be documented on the controlled medication count sheet and witnessed by another licensed nurse. Cross refer to F333. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 694711 Facility ID: CA060000715 If continuation sheet 12 of 12