Health inspection·April 23, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 follow facility policy and standards of practice for medication administration for three of four sampled residents, (Resident 1, Resident 2, and Resident 3) when: 1. Licensed Nurse (LN) 2, failed to sign off medications at the time of administration for Resident 1, Resident 2, and Resident 3; 2. LN 6 administered morning medications late to Resident 1 on 3/7/24; and, 3. LN 4 left the medication cart unattended with medications on top. These failures had the potential for Resident 1, Resident 2, and Resident 3 to receive a duplication of their medications, for Resident 1 to experience health effects from late medications, and for a resident to inadvertently take medications left out on the cart. Findings: 1a. A review of the Medication Administration Audit Report (MAAR), dated 3/5/24 to 3/7/24, indicated medications due for Resident 1 on 3/6/24 at 7 AM, 8 AM, and 11 AM were signed off by LN 2 as follows: Prednisone (a steroid medication) and Rivaroxaban (a blood thinner medication) due at 7 AM were signed off at 9 AM. Lasix (medication to decrease excess fluid in the body) due at 7 AM was signed off at 3:40 PM. Atenolol (a blood pressure medication) due at 8 AM, was signed off at 3:40 PM. Atrovent Inhalation (an inhaled medication to treat lung disease) due at 11 AM, was signed off at 12:40 PM b. A review of the MAAR, dated 4/10/24 to 4/11/24, indicated medications due for Resident 2, on 4/11/24, at 7 AM, 7:30 AM, and 9 AM, were signed off by LN 2 as follows: Farxiga (for diabetes – a disease which affects blood sugars) due at 7 AM, was signed off at 2:08 PM. Page 1 of 3 555245 555245 04/23/2024 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0755 Metformin (for diabetes), due at 7:30 AM, was signed off at 2:02 PM. Level of Harm - Minimal harm or potential for actual harm Amoxicillin (an antibiotic for infection), due at 9 AM, was signed off at 2:02 PM. Aspirin (medication used to prevent blood clots), due at 9 AM, was signed off at 2:02 PM. Residents Affected - Some Donepezil (medication for dementia - a loss of brain function which affects memory, thinking, language, or behavior), due at 9 AM, was signed off at 2:03 PM. Clonidine patch (medication applied to the skin for blood pressure control), due at 9 AM, was signed off at 2:02 PM. Losartan (for high blood pressure), due at 9 AM, was signed off at 2:05 PM. Metoprolol (for high blood pressure and heart conditions), due at 9 AM, was signed off at 2:05 PM. Multivitamin, due at 9 AM, was signed off at 2:06 PM. Potassium (an electrolyte supplement), due at 9 AM, was signed off at 2:06 PM. Rybelsus (medication for diabetes), due at 9 AM, was signed off at 2:06 PM. Glimepiride (medication for diabetes) due at 9 AM, was signed off at 2:04 PM. Vascepa (used to reduce triglycerides, a type of fat in the blood), due at 9 AM, was signed off at 2:04 PM. Hydrochlorothiazide (a blood pressure medication, also reduces excess fluids), due at 9 AM, was signed off at 2:04 PM. c. A review of the MAAR, dated 4/14/24 to 4/16/24, indicated medications due for Resident 3 on 4/16/24, at 9 AM and 12 PM, were signed off by LN 2 as follows: Metoprolol, due at 9 AM, was signed off at 1:34 PM. Vancomycin (an antibiotic) due at 12 PM, was signed off at 1:35 PM. During an interview with LN 2, on 4/23/24, at 3:50 PM, LN 2 stated she administered medications on time, and when she had time later, she signed them off. During an interview with LN 4, on 4/23/24, at 4:45 PM, LN 4 stated the importance of signing off medications after you administer them was to ensure all medications due were administered. During an interview with LN 5, on 4/23/24, at 5 PM, LN 5 stated she signed off medications after administration, she did not wait to sign them off later as this placed residents at risk for medication error. During an interview with the Director of Nurses (DON), on 4/23/24, at 5:25 PM, the DON stated the importance of documenting medications when given, was proof that the medication was administered. 555245 Page 2 of 3 555245 04/23/2024 North Park Post-Acute 2586 Buthmann Ave Tracy, CA 95376

F 0755 Level of Harm - Minimal harm or potential for actual harm 2. During an interview with LN 6 on 4/24/24, at 11:49 AM, LN 6 stated she passed the medications late to Resident 1 on 3/7/24, for the 7 AM doses. A review of the Medication Administration Audit Report (MAAR), dated 3/5/24 to 3/7/24, indicated the following medications were administered late to Resident 1: Residents Affected - Some Lasix Oral Tablet 40 MG [milligrams a unit of measure] .Give 3 tablet by mouth in the morning for HTN [high blood pressure] .Schedule date: 03/07/24 07:00 [7 AM] .Administration Time: 03/07/24 8:56 [AM] . Prednisone Oral Tablet .5 MG . Give 2 tablet by mouth in the morning for asthma [breathing difficulties] .Schedule Date: 03/07/24 07:00 .Administration Time: 03/07/24 09:03 [AM] . Rivaroxaban Oral Tablet 10 MG . Give 2 tablet by mouth in the morning .Schedule Date: 03/07/24 07:00 .Administration Time: 09:04 [AM] . During an interview with the DON on 5/3/24, at 1:42 PM, the DON explained the importance of administering medications on time was to ensure the therapeutic effect of the medication. 3. During a concurrent medication pass observation and interview with LN 4 on 4/23/24, at 4:45 PM, LN 4 was observed preparing medications for administration and was interrupted by a resident's family member. LN 4 left the medication cart with prepared medications on top of the cart unattended. LN 4 returned to the medication cart, apologized to the Department for leaving the medications unattended, and continued with the medication pass. LN 4 explained the importance of securing the medication was anything could happen; anyone could take them. During an interview with the DON on 4/23/24, at 5:25 PM, the DON explained the importance of securing medications was to make sure no other residents had access to medications that are not prescribed, for the safety of the residents. A review of the facility policy titled, Administering Medications, revised December 2012, indicated, .Medications shall be administered in a safe and timely manner, and as prescribed .Medications must be administered within one (1) hour of their prescribed time .During administration of medications, the medication cart will be kept closed and locked when out of sight of the mediation nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must clearly be visible to the personnel administering mediations, and all outward sides must be inaccessible to residents or others passing by .If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose . 555245 Page 3 of 3