Health inspection·August 22, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received medication as ordered. The facility also failed to notify the physician when Resident 1 did not receive this medication. These failures had the potential to compromise Resident 1's health and well-being. Residents Affected - Few Findings: Review of Resident 1's medical record indicated she was admitted to the facility on [DATE] and had the diagnosis of hyperlipidemia (an abnormally high concentration of fats in the blood). Review of Resident 1's [Hospital] Patient Summary, dated 5/24/23, indicated she received rosuvastatin (medication used to treat hyperlipidemia) while she was in the hospital prior to her admission to the facility. The [Hospital] Patient Summary further indicated Resident 1 was to continue receiving rosuvastatin at the facility. Review of Resident 1's Order Summary Report from the facility indicated she had a physician ' s order, dated 5/24/23, for rosuvastatin 20 milligrams (mg, unit of dose measurement) one tablet by mouth at bedtime for hyperlipidemia. Resident 1's medication administration record (MAR) was reviewed. From 5/24/23 to 6/1/23, and from 6/3/23 to 6/4/23, the number 9 was documented in the section designated to document the administration of rosuvastatin 20 mg at bedtime. Further review of the MAR indicated if the number 9 was documented, it meant to See Nurse Notes. Resident 1's Progress Notes from 5/24/23 to 6/1/23, and from 6/3/23 to 6/4/23, were reviewed. The notes indicated the facility did not have Resident 1 ' s rosuvastatin on hand. Some of the documentation regarding Resident 1's rosuvastatin indicated, no supply or no available supply or pending delivery. During an interview and concurrent record review with licensed vocational nurse A (LVN A) on 8/22/23 at 10:23 a.m., LVN A reviewed Resident 1's medical record and confirmed the resident did not receive rosuvastatin 20 mg at bedtime because the medication was not available in the facility. Further review of Resident 1's medical record indicated there was no documentation that the nurses followed up with the pharmacy regarding the delivery of rosuvastatin. There was also no documentation that the nurses notified Resident 1's physician to inform him the resident had not received this medication. Page 1 of 2 555060 555060 08/22/2023 Windsor the Ridge Rehabilitation Center 350 Iris Drive Salinas, CA 93906

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review with the director of nursing (DON) on 8/22/23 at 11:29 a.m., she confirmed if a medication was not available in the facility, the nurses should follow up with the pharmacy until the facility received the medication. The DON also confirmed that if a resident did not receive a medication as ordered, the nurses should notify the resident's physician. The DON reviewed Resident 1's medical record and acknowledged there was no documentation that the nurses followed up with the pharmacy regarding the delivery of rosuvastatin. The DON also acknowledged there was no documentation that the nurses informed Resident 1's physician that she had not been receiving this medication. During an interview with the consultant pharmacist (CP) on 8/22/23 at 2:17 p.m., he explained he did not have information regarding the delivery of Resident 1's rosuvastatin to the facility. The CP stated he would contact the pharmacy and have the information emailed. During an interview and concurrent record review with LVN B on 8/22/23 at 3:11 p.m., LVN B reviewed Resident 1's medical record and confirmed the resident did not receive rosuvastatin 20 mg at bedtime because the medication was not available in the facility. LVN B stated she did not remember following up with the pharmacy or notifying Resident 1's physician regarding this medication. LVN B confirmed there was no documentation that she followed up with the pharmacy or notified the physician regarding Resident 1's rosuvastatin. Review of an email from the CP, dated 8/22/23 indicated, The patient [Resident 1] had a documented allergy to statins [class of medication that includes rosuvastatin] so the pharmacy requested for clarification on the DRR [drug regimen review]. The email further indicated the pharmacy never received a response from the facility regarding the requested clarification, and never sent Resident 1's rosuvastatin to the facility. The facility's policy titled Medication Administration-General Guidelines, dated 10/2017 indicated, Medications are administered in accordance with written orders of the attending physician. The facility's policy titled Medication Orders, dated 4/2008 indicated, The prescriber is contacted for direction when the medication will not be available. 555060 Page 2 of 2