Health inspection·October 10, 2023

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 interview, medicalrecord review, and facility P&P review, the facility failed to ensure the controlled substance medications (medications with high risk for abuse andaddiction) were appropriately accounted for one of two sampled residents (Resident 1). This failure had the potential to negatively affect the health and safety of the resident. Findings: Review of the facility's P&P titledControlled Medications dated 8/2014 showed the medications included in the Drug Enforcement Administration (an agency which enforces the United States' controlled substance laws and regulation) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. When a controlled medication is administered, the license nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): A. Date and time of administration B. Amount administered C. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. D. Initials of the nurse administering the dose on the MAR after the medication is administered. Medical record review for Resident 1 was initiated on 10/6/23. Resident 1 was admitted to the facility on [DATE]. Review of Resident's 1 Order Summary Report showed a physician's order dated 9/14/23,to administer hydrocodone-acetaminophen (a narcotic pain medication) oral tablet 10-325 mg one tablet by mouth every four hours as needed for moderate to severe pain, not to exceed three grams of acetaminophen per 24 hours. Review of Resident's 1 Antibiotic or Controlled Drug Record showed one tablet of hydrocodone-acetaminophen 10-325 mg was signed out on the following dates and times: - 9/17/23 at 1000 hours; (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: 555329 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 555329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA Palma Nursing Center 1130 LA Palma Ave Anaheim, CA 92801 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)