Health inspection·August 7, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure prescribed medications (meds) were administered as ordered by the physician for two of two sampled residents (Resident 1, Resident 2) As a result, Resident 1 was found unresponsive and life sustaining measures were performed including cardiopulmonary resuscitation (CPR). A. Resident 1 was admitted to the facility on [DATE] at 1:37 P.M., with a diagnosis of atherosclerotic heart disease of native coronary artery and atrial fibrillation (irregular heartbeat that affects blood flow) per the facilities admission record and admission note. A review of Resident 1's physicians orders (PO), dated [DATE], Indicated Resident 1 was a full code The PO's indicated Resident 1 was prescribed the following meds to be administered on [DATE] at 9 P.M. Risperidone (mood disorder med) 2 mg (milligram), one tablet (tab) by mouth (PO) in the evening. Trazodone HCl (an antidepressant) 50 mg, one tab PO at bedtime. Budesonide-Formoterol Fumarate (inhaler for chronic obstructive pulmonary disorder, COPD) 80-4.5 MCG (microgram)/ACT (actuation), 2 puffs twice a day. Carvedilol (cardiac med for high blood pressure) 25 mg, one tablet PO two times a day. Dronedarone HCL (med that helps maintain normal heart rhythm) 400 mg, one tablet PO, two times a day. Eliquis (blood thinner for clot prevention) 5 mg, one tablet PO, two times a day. A review of Resident 1's nursing note, dated [DATE] at 4:35 A.M., indicated, .New Admit, monitoring resident alert able to make simple needs known appears somewhat confused at times. A review of Resident 1's progress note, dated [DATE] at 7:58 A.M., indicated, . resident found not breathing, non-responsive by CNA, code blue immediately initiated. During an interview on [DATE] at 1:43 P.M, licensed nurse (LN) 1 stated, the LN should notify the pharmacy a new admission's medication orders, and the pharmacy will deliver the medications. LN 1 stated, if a new admission's evening medications are not delivered by administration time, the LN should pull the scheduled medications from the e-kit pyxis (emergency medication storage machine) if they are available. LN 1 stated nurses are instructed to call the pharmacy if the medication is an important medication and not available for administration. LN 1 stated if the medication is important enough to be in the e-kit, it is important to remove and give at the ordered time of administration. During an observation, interview and record review on [DATE] at 2:15 P.M., the assistant director of nursing (ADON) and director of nursing (DON) reviewed med inventory of the facility's e-kit pyxis. The inventory indicated the e-kit pyxis contained three of Resident 1's six prescribed evening meds including: 10 tabs of Eliquis 2.5mg 10 tabs of Carvedilol 6.25mg 18 tabs of Trazodone 50mg The e-kit pyxis did not contain any doses of Risperidone, Budesonide-Formoterol, or Dronedarone. A review of Resident 1's eMAR (electronic medication administration record) dated [DATE] indicated Resident 1 did not receive the following scheduled medications at 9 PM as ordered: RisperiDONE 2 mg PO TraZODone HCl 50 mg PO Budesonide-Formoterol Fumarate 80-4.5 MCG/ACT inhaler Carvedilol 25 mg PO Dronedarone HCl 400 mg PO Eliquis 5 mg PO A review of the e-kit transaction history dated, [DATE]-[DATE], indicated none of the three available Page 1 of 3 555136 555136 08/07/2025 Poway Healthcare Center 15632 Pomerado Road Poway, CA 92064

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications in the e-kit were ever removed to be administered to Resident 1. A review of Resident 1's medication administration progress notes, dated [DATE], indicated , .New admit; meds not here yet. , as the reason all six medications, scheduled for 9:00 P.M., were not administered. During an interview on [DATE] at 3:55 P.M., LN 2 stated upon admission to the facility a resident's medication orders will be reconciled and approved and submitted to be filled and delivered by the pharmacy. LN 2 stated the nurse will access medications in the ekit pyxis if they have not been delivered to the facility by the time of medication pass. LN 2 stated the physician should be notified if the med has not been delivered and is not in the ekit by the time of scheduled administration. Once the nurse administers the medication it should be charted as given in the medication administration record (MAR). LN 2 stated a resident who has a diagnosis of heart disease or atrial fibrillation would be at risk for developing cardiac complications such as a blood clots, headache, or chest pain if they did not receive ordered cardiac medications. During an interview on [DATE] at 3:31 P.M., the Nurse Practitioner (NP), stated the licensed nurse is supposed to notify the NP or physician when a new admission arrives to the facility and obtain verbal authorization over the phone for the resident's medications. The NP stated the approved resident medication list should be sent or called into the pharmacy and the medications should be delivered by the pharmacy. The NP stated if a resident is admitted to the facility at 4 P.M. and does not receive their evening medications the NP or the physician should be notified. A review of Resident 1's progress notes did not indicate the NP or the physician were notified Resident 1 did not receive evening medications or that the medications had not been delivered from the pharmacy. During an interview and record review on [DATE] at 4:39 P.M., the DON reviewed Resident 1's MAR and progress notes, dated [DATE]. The DON acknowledged the MAR indicated Resident 1 did not receive multiple medications scheduled for the 9:00pm Med pas on [DATE], including cardiac medications, carvedilol and Eliquis, which were available to withdraw from the e-kit pyxis. The DON stated if Resident 1 was admitted to the facility at 1:37 P.M. the 9:00 P.M. medications should have been given. The DON stated if the medications had not arrived from the pharmacy by medication pass they should have been pulled out of the e-kit pyxis. The DON stated Resident 1 was admitted to the facility after a hospital stay where he had elevated troponins (blood marker for heart attack) and an abnormal EKG (electrocardiogram that reads the rhythm and rate of the heart). The DON stated, I don't know what to say. They should have checked the pyxis. The DON stated medication nurses were expected to pull needed medication from the pyxis if medication had not arrived by the time of scheduled administration. During an interview on [DATE] at 10:42 A.M., the facility pharmacist (FP), stated Resident 1's orders were received by the pharmacy on [DATE] at 8:33 P.M., and delivered to the facility on [DATE] at 2:42 A.M. The FP stated once orders are sent to the pharmacy, they will be filled and sent to the facility on the next shipment. The FP stated they have several deliveries a day. The FP stated the facility is able to call in a one-time dose if a prescribed medication is not in the ekit. B. Resident 2 was admitted to the facility on [DATE] with a diagnosis of COPD and pneumonia (respiratory infection) per the facility admission record. During an interview on [DATE] at 2:35 P.M., Resident 2 stated she was admitted a few days ago from a local hospital following a respiratory infection. Resident 2 stated she arrived at the facility after dinner the day she was admitted . Resident 2 stated she did not get all her evening medications or ordered respiratory treatments but was unable to recall which medications she did not get. A review of Resident 2's Physician's orders, EMAR, and progress notes, dated [DATE], indicated the following medications were scheduled for 9:00 P.M and charted as not given: Ipratropium Bromide Inhalation Solution 0.02%, via nebulizer Atrovent HFA Inhalation Aerosol Solution 17 MCG/ACT, inhaler Ipratropium-Albuterol Inhalation Solution 2.5-0.5 555136 Page 2 of 3 555136 08/07/2025 Poway Healthcare Center 15632 Pomerado Road Poway, CA 92064

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few MG/3 ML, via nebulizer ? A review of the facility policy titled, Administering Medications, revised [DATE], indicated, Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 5. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. enhancing optimal therapeutic effect of the medication. 7. Medications are administered within one (1) hour of their prescribed time 555136 Page 3 of 3