Health inspection·April 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. Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was evaluated to self-administer medication when lidocaine (medication used to relieve pain) was left at the bedside. This failure resulted in Resident 1 having medication at bedside and the potential to self-administer medication incorrectly. Findings: During a concurrent observation and interview on 4/7/25 at 11:10 a.m. with Resident 1 in Resident 1's room, Resident 1 was holding a washcloth up to her mouth and appeared in pain. There was a medication cup with a clear gel looking substance on Resident 1's over bed table. Resident 1 stated she had a bad tooth, and was provided the lidocaine in the medication cup from the nurse so she could use it when she was in pain. During a concurrent observation and interview on 4/7/25 at 11:18 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 1's room, LVN 1 stated the medication cup that was on Resident 1's over bed table contained lidocaine. LVN 1 stated when a resident was to self-administer medication an evaluation was completed to make sure the resident was safe to administer the medication and understands the physician order. LVN 1 stated if the resident was deemed safe to self-administer medication, they will have the physician's orders at bedside and a lock box to keep the medication in. LVN 1 stated Resident 1 was not evaluated to self-administer medications. During an interview on 4/7/25 at 11:40 a.m. with LVN 2, LVN 2 stated when she administered Resident 1's medications in the morning the medication cup with the lidocaine was on the over bed table. LVN 2 stated Resident 1 will sometimes have the lidocaine at bedside so she can reapply a little over time. LVN 2 stated the lidocaine should not have been left at bedside. During an interview on 4/7/25 at 12:11 a.m. with Director of Nursing (DON), DON stated Resident 1 did not have physician orders to self-administer medications and there should not have been lidocaine at the bedside. During a review of the facility's policy and procedure (P&P) titled Self-Administration of Medications dated 2/2021, the P&P indicated, As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. the medication is appropriate for self-administration; b. The resident able to read and understand medication labels; c. The resident can follow directions and tell time Page 1 of 2 555208 555208 04/07/2025 Westgate Gardens Care Center 4525 W. Tulare Ave. Visalia, CA 93277

F 0755 Level of Harm - Minimal harm or potential for actual harm to know when to take the medication; d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication. Residents Affected - Few 555208 Page 2 of 2