Health inspection·June 14, 2023

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with the hydrocodone-acetaminophen 5-325 mg PRN order revealed two [1/2] tablets were given on 6/14/23 at 9:07 a.m., but not signed out on the CDR count sheet. During a concurrent interview and record review on, 6/14/23 at 1:15 p.m., with Nurse Manager (NM), NM confirmed the CDR count sheet for Resident 2's hydrocodone-acetaminophen 5-325mg PRN order and the actual number of medications in the bubble pack did not match. NM further stated LNs should sign out controlled medications on the CDR count sheet when the medication is removed from the controlled storage. The CDR count sheet and the actual number of supplies in the bubble pack should match. During a review of Resident 3's clinical records, it indicated, Resident 3 was recently admitted to the facility with diagnoses including stroke (disrupted blood flow to the brain cells causes parts of the brain to die) with hemiparesis (inability to move one side of the body). The Resident had a BIMS score of 15 meaning their cognition was still intact. Resident 3 required extensive assistance in performing activities of daily living (ADLs). During a review of Resident 3's POR for June 2023, it indicated Resident 3 had an order for hydrocodone schedule II 5-325 mg tablet (generic for brand name Norco), give 1 tablet every 6 hours as needed for severe pain. During a concurrent interview and record review of Resident 3's MAR, Resident 3 received 1 tablet hydrocodone-acetaminophen 5-325 mg on 6/10/2023 at 2:07 [02:07] a.m. and 1 tablet at 6:28 [18:28] p.m. The CDR count sheet for the said medication revealed it was signed one time only on 6/10/23 at 12 [2400] midnight. The MAR and the CDR count sheet did not match the number of times the medication was administered and the period it was given. Also found attached to the CDR count sheet was a note which indicated, 6/10/23 NOC shift nurse didn't chart Norco at midnight in MAR. LN 1 verified a post-it note was attached to the CDR count sheet, but did not pay attention to the note when she counted the narcotics with the night (NOC) shift LN. During a concurrent interview and record review on, 6/14/23 at 2:30 p.m., with NM, NM verified the MAR and the CDR count sheet for Resident 3's hydrocodone-acetaminophen 5-325 mg order did not match. NM stated LNs should always make sure to sign both the MAR and the CDR count sheet when giving controlled medications to minimize incidence of medication errors. NM insisted she did not know who wrote the note found attached to the CDR count sheet. During an inspection of the green unit and purple unit narcotic book with LN 2 on, 6/14/23 at 2:35 p.m., documents revealed several incomplete CDR count sheets. The CDR count sheets were not filled out completely to indicate the actual total number of medications received, the date it was received, and the staff who received it. LN 2 indicated the CDR count sheet should be completed by the staff who received it. During a concurrent interview and record review on 6/14/23, at 3:12 p.m., NM confirmed the CDRs were not filled out properly/completely by the LN who received it and stated, LNs should complete the count sheets before putting it in the narcotic book. During a review of the facility's Policy and Procedure (P&P) titled Medication Administration Controlled Medications dated 11/2017, the P&P indicated When controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record when removing dose from controlled storage: a. Date and time of administration b. amount administered c. Signature of the nurse administering the dose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555083 If continuation sheet Page 2 of 3 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 555083 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Manzanita Healthcare Center 5318 Manzanita Avenue Carmichael, CA 95608 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's P&P titled Medication Administration General Guidelines dated 01/2021, the P&P indicated Documentation: The individual who administers the medication dose, records the administration . In no case should the individual who administered report off-duty without first recording the administration of any medications. During a review of the facility's P&P titled Medication Ordering and Receiving From Pharmacy Provider Ordering and Receiving Controlled Medications dated 01/2020, the P&P indicated The pharmacy or the nursing care center prepares an individual resident controlled substance record/receipt/log for each controlled substance medication prescribed for a resident. This log is placed in the MAR or Narcotic book to be counted every shift. The following information is completed: .f. Date received; g. Quantity received; h. Name of person receiving the medication supply. Event ID: Facility ID: 555083 If continuation sheet Page 3 of 3