Health inspection·September 4, 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 interview, and record review, the facility failed to ensure medications were administered according to physician orders for one of three residents (Resident 2) when Resident 2 missed a dosage of three medications on 8/20/25.This failure had the potential to negatively affect the health and well-being of Resident 2, and the efficacy of the medications being administered.Findings: A review of Resident 2's admission RECORD, indicated that Resident 2 was admitted to the facility in 2025 with diagnoses which included displaced intertrochanteric fracture of right femur (a break in the upper part of the hip in which the bones are out of place), and hypertension (a condition in which the force of the blood pushing against the blood vessel walls is consistently too high. This causes the heart to work harder to pump blood). A review of Resident 2's Physician Order Summary, indicated, .AmLODIPine Beselyte [medication to treat hypertension] Tablet 10MG [milligram, a unit of measure] Give 1 tablet by mouth one time a day for HTN [hypertension].Order Date.08/19/2025.Start Date.08/20/2025.A review of Resident 2's Physician Order Summary, indicated, .Famotidine Oral Tablet [medication to decrease the amount of acid produced in the stomach] 40 MG Give 1 tablet by mouth in the morning for GERD [Gastroesophageal Reflux Disease, a condition where stomach acid flows back up into the esophagus and causes heartburn].Order Date.08/19/2025.Start Date.08/20/2025.A review of Resident 2's Physician Order Summary, indicated, .Linzess Oral Capsule [medication used to treat chronic constipation] 145 MCG [microgram, a unit of measure].Give 1 capsule by mouth one time a day for Irritable Bowel Syndrome [IBS, a condition that causes abdominal bloating, cramping, constipation, and diarrhea].Order Date.08/19/2025.Start Date.08/20/2025.A review of Resident 2's Care Plan Report, indicated, .Focus.[Resident 2] has altered cardiovascular status r/t [related to] HTN, history of CVA [cerebrovascular accident, a result of disrupted blood flow of the brain due to problems with blood vessels that supply it, also known as a stroke].Goal.[Resident 2] will be free from s/sx (signs/symptoms) of complications.Date Initiated.08/20/2025.Interventions/Tasks.Administer medications as ordered.A review of Resident 2's Care Plan Report, indicated, .Focus.Resident 2] has GERD r/t hyperacidity [increased acid in the stomach].Goal.[Resident 2] will remain free from discomfort, complications, or s/sx related to dx [diagnosis] of GERD.Date Initiated.08/20/2025.Interventions/Tasks.Administer medications as ordered.A review of Resident 2's Care Plan Report, indicated, .Focus.[Resident 2] has an alteration in Gastro-Intestinal status r/t IBS [irritable bowel syndrome, a long term condition affecting the large intestine with symptoms of abdominal pain, bloating cramping, gas, and constipation].Goal.[Resident 2] will remain free from discomfort, complications or s/sx.Date Initiated.08/20/2025.Interventions/Tasks.Administer medications as ordered.A review of Resident 2's Medication Administration Record (MAR, a document listing medications and monitoring parameters), dated August 2025, indicated a 13 was documented for the 9 a.m. dose of Amlodipine on 8/20/25. The chart code on the August 2025 MAR indicated that 13 indicated Drug not available.A review of Resident 2's MAR, dated August 2025, indicated a 13 was documented for the 9 a.m. dose of Linzess on Page 1 of 3 555307 555307 09/04/2025 Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/20/25.A review of Resident 2's MAR, dated August 2025, indicated a 7 was documented for the 6 a.m. dose of Famotidine on 8/20/25. The chart code on the August 2025 MAR indicated that 7 indicated Sleeping.During an interview on 9/4/25, at 10:07 a.m., with LN 2, LN 2 stated that if a resident's medication was not available to administer during medication administration time, she would check to see if the medication was in the e-kit in the medication storage room. LN 2 stated that there was a list of medications and dosages available in the e-kit, so if the medication was in the e-kit, she would take the medication out of the e-kit and fill out the form indicating which medication she took and fax the form to the pharmacy so that the pharmacy could replace the e-kit. LN 2 stated that if the medication was not in the e-kit, she would call the resident's physician to let the physician know that the medication was not available in the medication cart or the e-kit. LN 2 stated that the physician sometimes gave a one-time order to give the medication when it arrived late, then the regular medication times resumed. LN 2 stated that she would document that the medication was not available and what steps she took to resolve it in the resident's progress notes. During a concurrent interview and record review on 9/4/25, at 12:10 p.m., with the Nurse Supervisor (SUP), Resident 2's electronic medical record (EMR) was reviewed. The SUP confirmed that on Resident 2's MAR on 8/20/25, at 9 a.m., a 13 was entered for the dose of Amlodipine and the dose of Linzess; where the LN would document that the medications were given. The SUP further confirmed the 13 was a code that indicated Drug not available. The SUP confirmed that on 8/20/25, at 6 a.m., a 7 was entered for the dose of Famotidine; where the LN would document that the medication was given. The SUP further confirmed the 7 was a code that indicated Sleeping. The SUP further confirmed that there was no progress notes documented in Resident 2's EMR on 8/20/25 that indicated why the medications were not given or that the physician or pharmacist was notified. The SUP stated that her expectation was that if a resident's medications were not available to give during the medication administration time, the LN called the pharmacy for follow up and notified the resident's physician. The SUP stated the LN needed to document in the resident's progress notes that the medication was not given and what was done about it. The SUP further stated that, if necessary, the LN needed to endorse a follow up to the oncoming shift LN. The SUP acknowledged that the facility policy was not followed. The SUP stated the risk was that Resident 2's medications were not given as ordered. The SUP further stated that Resident 2's blood pressure could elevate if Resident 2 did not receive the Amlodipine, Resident 2 could become constipated if Resident 2 did not receive Linzess, and Resident 2 could have indigestion if Resident 2 did not receive Famotidine. The SUP stated that the facility had a medication dispensing machine and was in the process of educating the staff on how to use the machine.During a phone interview on 9/4/25, at 1:29 p.m., with the Pharmacy Consultant (PHARM), the PHARM stated that there was a new medication dispensing machine at the facility and the medications needed for the residents were all in the machine. The PHARM further stated that if there was a medication that the staff needed that was not available in the machine, then the staff could get the medication from the e-kit. The PHARM stated that accessing the medications from the medication dispensing machine was the first priority at the facility, but if a LN did not have access to the medication dispensing machine the LN could get the medication from the e-kit. The PHARM further stated that using the medication dispensing machine was faster than using pharmacy delivery for medications. The PHARM stated that the LNs still needed to communicate with the physician and the pharmacy when medication doses were not available.A review of a facility policy and procedure (P&P) titled, Administering Medications, revised April 2019, indicated, .Policy Statement.Medications are administered in a safe and timely manner, and as prescribed.Policy Interpretation and Implementation.4. Medications are administered in accordance with prescriber 555307 Page 2 of 3 555307 09/04/2025 Clearwater Healthcare Center 1517 East Knickerbocker Drive Stockton, CA 95210

F 0755 orders, including any required time frame.7. Medications are administered within one (1) hour of their prescribed time. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555307 Page 3 of 3