F 0661
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure necessary information is communicated to the resident, and receiving health care provider at the
time of a planned discharge.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to accurately complete a medication reconciliation (the
process of identifying the most accurate list of all medications that the patient is taking, including name,
dosage, frequency, and route) on post- discharge medications for one of three residents (Resident 1) when
Resident 1 was discharged home with a discontinued (no longer provided) medication.
This failure had the potential for Resident 1 to take an unprescribed medication in error which could
negatively affect his health and well-being.
Findings:
A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility in 2024 with
diagnoses that included depression (a mental health condition that involves a persistent feeling of sadness
and loss of interest that interferes with daily life) and muscle weakness.
A review of Resident 1's Order Summary Report, (list of physician orders) dated 6/27/24, indicated
Resident 1 was prescribed Mirtazapine (medication to treat depression) 7.5 mg (milligram- a unit of
measure) one tablet at bedtime. Further review of the record indicated the order for Mirtazapine was
discontinued on 6/28/24.
A review of Resident 1's Medication Administration Record, (MAR) indicated Resident 1 received
Mirtazapine on 6/27/24.
A review of Resident 1's Discharge Instructions, with an effective date of , .Date of discharge: [DATE] .Final
Discharge Location: Home/Family Assist .7/31/24, indicated Medications .Please see attached medication
instruction form .
A review of Resident 1's Transfer/ Discharge Report, dated 7/31/24, indicated Mirtazapine was not found on
the list of Resident 1's current medications.
A review of Resident 1's Discharge Meds Release ., (list of medications sent home when the patient is
discharged ) dated 8/1/24, indicated Mirtazapine was 1 of 12 medications sent home with Resident 1.
During a concurrent interview and record review on 10/18/24, at 10:45 a.m., with the Director of Nursing
(DON) and Licensed Nurse (LN) 1, Resident 1's discharge records were reviewed. LN 1 confirmed the
nurse that discharged Resident 1 gave Mirtazapine, a discontinued medication to Family Member
(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:
555186
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
555186
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/18/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Lincoln Square Post Acute Care
1032 N. Lincoln Street
Stockton, CA 95203
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 0661
Level of Harm - Minimal harm
or potential for actual harm
(FM) 1 to take home that was not on the list of medications in Resident 1's discharge instructions. LN 1
stated that when the error was discovered by facility administration, the nurse was counseled and no longer
worked at the facility. LN 1 further stated FM 1 should not have been given a medication that was not listed
on Resident 1's current discharge medication list. The DON and LN 1 both confirmed there was a risk to
Resident 1 when a discontinued medication was sent home with the resident and FM 1.
Residents Affected - Few
During a phone interview on 10/18/24, at 11:29 a.m., with FM 1, FM 1 confirmed Mirtazapine was one of
the medications that was sent home with Resident 1 when he was discharged from the facility. FM 1 stated
she did not give Mirtazapine to Resident 1 as it was not listed on his discharge instructions list of
medications.
During a review of a facility policy and procedure (P&P) titled, Discharge Medications, dated December
2016, indicated, .2. The Charge Nurse shall verify that the medications are labeled consistent with current
physician orders including instructions for use .4. The nurse will reconcile pre-discharge medications with
the resident's post-discharge medications. The medication reconciliation will be documented. 5. The nurse
shall review medication instructions with the resident, family member or representative before the resident
leaves the facility .
During a review of a facility P&P titled, Discharge Summary and Plan, dated December 2016, indicated,
.When a resident's discharge is anticipated, a discharge summary and a post-discharge plan will be
developed to assist the resident to adjust to his/her new living environment .2. The discharge summary will
include .Medication Therapy (all prescription and over-the-counter medications taken by the resident
including dosage, frequency of administration, and recognition of significant side effects that would be most
likely to occur in the resident) .As part of the discharge summary, the nurse will reconcile all pre-discharge
medications with the resident's post-discharge medications. The medication reconciliation will be
documented .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555186
If continuation sheet
Page 2 of 2
