Health inspection·February 24, 2025

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. Based on observation, interview, and record review for one of three sampled residents, Resident 2. The facility failed to waste an Ativan (medication used to treat anxiety) 0.5 mg(milligrams) per facility-controlled narcotic (a medication tightly controlled by the government because it may be abused or cause addiction) protocol. This deficient practice resulted in an inaccurate Ativan 0.5mg count for Resident 2. Findings: During record review, Resident 2's admission Record indicated the facility admitted Resident 2 on 1/15/2025 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), epilepsy (a condition that causes sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), displaced left femur fracture (broken thigh bone), dysphagia (difficulty swallowing), dementia (a progressive state of decline in mental abilities), overactive bladder (problem that causes sudden need to urinate), hyperlipidemia (high fat in the blood), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought), gastroesophageal reflux disease (indigestion/heartburn), Anxiety (a mental condition of constant worry or fear for unknown reason) presence of cardiac pacemaker. During record review, Resident 2's Physician Order dated 1/15/2025 indicated Ativan 0.5mg, give 1 tablet four times a day for anxiety manifested by inability to relax due to current medical condition. During record review, Resident 2's Minimum Data Set (MDS-a resident assessment tool) dated 1/22/2025 indicated Resident 2's cognition (mental ability to make decisions for daily living) was not intact. The MDS indicated Resident 2 required maximal assistance (helper does less than half the effort. Helper lifts or holds trunk or limb and provides more than half the effort to complete the activity) with toileting, personal hygiene, and transfers (moving between surfaces) from bed to chair. On 2/18/2025 the California Department of Public Health (CDPH) received a complaint alleging narcotic medications intended for residents have gone missing during the day shift. During a concurrent observation, interview, and record review on 2/24/2025 from 11:08 a.m. with the licensed vocational nurse (LVN) at Station # (number) 1 of medication cart #1, Resident 2's Ativan 0.5mg bubble pack was observed with 31 pills. The LVN stated, Oh, I gave one (Ativan 0.5 mg) this Page 1 of 2 555039 555039 02/24/2025 Fireside Health Care Center 947 3rd Street Santa Monica, CA 90403

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few morning that is why there are 31 pills left. Resident 2s' controlled medication count sheet for Ativan 0.5mg was reviewed. A circle was observed around #33 on Resident 2's-controlled medication count sheet for Ativan 0.5mg. Also, there was no date or time next to the circle around the #33. The LVN stated, That means there should be 33 pills left. I gave one (tablet) to the resident this morning and I have not documented yet and I dropped one during the count with the off going unnamed nurse that I forgot to waste. The LVN then signed Resident 2s' controlled medication count sheet for Ativan 0.5mg the date and time next to #33. The LVN then took the sheet to another charge nurse at the nursing station and had that charge nurse sign Resident 2's-controlled medication count sheet for Ativan 0.5 mg. The LVN stated, The waste (Ativan) needs to be signed by two licensed nurses. During record review, Resident 2's medication administration record (MAR- a form where medications are documented after they are given) dated 2/24/2025 for Ativan 0.5mg timed 9:00a.m. was blank. During an interview on 2/24/2025 at 12 p.m., the Director of Nursing (DON) stated, Narcotic waste should be witnessed and signed by two licensed nurses. In this case, the LVN should have reported the forgotten waste (Ativan) to the DON and the DON could have called the unnamed off going nurse (charge nurse who co-signed for the Ativan waste) to verify the waste. During record review, the facility policy, and procedures (P&P) titled, Medication Administration dated 1/25/2022 indicated, the time and dose of the drug or treatment administered to the resident will be recorded in the resident's individual medication record by the person who administered the drug. During record review, the facility P&P titled, Discarding and Destroying Medications , dated 10/2024 indicated: For unused, non-hazardous controlled substances that are not disposed of by an authorized collector, the EPA recommends destruction and disposal of the substance with other solid waste following the steps below: a. Take the medication out of the original containers. b. Mix medication, either liquid or solid, with an undesirable substance. Undesirable substances include sand, coffee grounds, kitty litter, or other absorbent materials. Place the waste mixture in a sealable bag, empty can, or other container to prevent leakage. c. Dispose with the solid waste (i.e., regular trash) in the presence of two witnesses. d. Document the disposal on the medication disposition record. e. Include the signature(s) of at least two witnesses. 555039 Page 2 of 2