Health inspection·October 23, 2024

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, the facility failed to provide pharmaceutical services to meet the needs of one of two sampled residents (Resident 1) when a medication used to control pain was not ordered and delivered. This failure had the potential for Resident 1 to experience nerve pain. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in the winter of 2024, with diagnosis of, but not limited to, Type 2 Diabetic Mellitus (DM) (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), acute and chronic respiratory failure with hypoxia (condition in which your lungs have a hard time loading your blood with oxygen or removing carbon dioxide). During a review of Resident 1's Order Summary Report dated 10/23/2024, the Order Summary Report indicated that Gabapentin (a medication used for nerve pain, which can be caused by different conditions, including diabetes and shingles) Oral Capsule 100 MG (Gabapentin) was ordered for Resident 1 on 5/02/24 with the following directions: Give 1 capsule by mouth three times a day for DM Neuropathy (weakness, numbness, and pain from nerve damage, usually in the hands and feet.) During a medication pass observation and interview on 10/23/24 at 12:13 PM with Licensed Nurse (LN) 1, medications were observed being given to Resident 1. During the observation, LN 1 stated that she did not administer Resident 1's Gabapentin medication because the medication was not available. During an interview on 10/24/24 at 12:18 PM with Resident 1, Resident 1 confirmed that she did not receive her dose of Gabapentin. During an interview on 10/23/24 at 1:01 PM with the Infection Preventionist (IP), the IP stated that Gabapentin was an important medication because it was used for pain management. The IP stated that the nurses should give medications as ordered by the doctor. The IP also stated that if residents do not get the pain medication as prescribed, it could lead to pain for them. The IP further stated that nurses should order medications when there are four to six pills left because it would allow time for the pills to arrive from the pharmacy. During an interview on 10/23/24 at 1:12 PM with the Director of Staff Development (DSD), the DSD (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555105 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 555105 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/23/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Noble Care Center 2740 North California Street Stockton, CA 95204 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)