Health inspection·November 22, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document medication as given within the ordered administration time for four of four Sampled residents (Residents 1, 2, 3, and 4). This failure had the potential to result in the medication ' s intended therapeutic effect being compromised or possibly leading to inadequate disease management or symptom control. Findings: During a review of Resident 1 ' s admission record, Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that include bipolar disorder unspecified (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) , and insomnia (trouble falling asleep or staying asleep). During a review of Resident 1 ' s Electronic Medication Administration Record (EMAR), the EMAR indicated a medication scheduled for November 22, 2024, at 0900 (9:00 am), was administered at 11:26 am and documented at 11:32 am by LVN 3. During a review of Resident 2 ' s admission record, Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that include dementia (a progressive state of decline in mental abilities), major depressive disorder, and schizophrenia. During a review of Resident 2 ' s EMAR, the EMAR indicated a medication scheduled for November 22, 2024, at 0900, was administered at 10:48 am and documented at 10:50 am by LVN 3. During a review of Resident 3 ' s admission record, Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that include epilepsy (a brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), schizophrenia, and muscle weakness. During a review of Resident 3 ' s EMAR, the EMAR indicated a medication scheduled for November 22, 2024, at 0900, was administered at 10:06 am and documented at 10:07 am by LVN 3. During a review of Resident 4 ' s admission record, Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that include neuropathy, (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) anemia (a Page 1 of 3 555368 555368 11/22/2024 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0755 condition where the body does not have enough healthy red blood cells), and schizophrenia. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 4 ' s EMAR, the EMAR indicated a medication scheduled for November 22, 2024, at 0900, was administered at 11:23 am and documented at 11:24 am by LVN 3. Residents Affected - Some During an interview on 11/22/2024 at 3:00 pm with LVN 3, LVN 3 stated the electronic medical record system they are using is new as of October 8, 2024, and that he is slow documenting medication times. LVN 3 stated medication administration should be done within one hour before or after scheduled time. LVN 3 stated he received training, but feels he needs more but did not mention this to management. During an interview on 11/22/2024 at 4:45 pm with the Director of Nursing (DON), the DON stated the facility switched from paper charting to EMAR on October 8, 20224. DON stated staff was provided twenty-four-hour access to training that can be done at home, in addition to group sessions done in office in a conference room on. The DON stated LVN 3 has not asked for help and that she double checks the staffs work almost every day. DON could not provide documentation for the trainings. During a review of a facility policy entitled Medication Administration dated 2024, indicated administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. During a review of a facility policy entitled Documentation Policy dated 2024, indicated entries must be completed as soon as possible after the care is provided or a significant event occurs. All nursing staff will receive training on proper documentation practices a part of their orientation and ongoing education. Based on interview and record review, the facility failed to document medication as given within the ordered administration time for four of four Sampled residents (Residents 1, 2, 3, and 4). This failure had the potential to result in the medication's intended therapeutic effect being compromised or possibly leading to inadequate disease management or symptom control. Findings: During a review of Resident 1's admission record, Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that include bipolar disorder unspecified (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), paranoid schizophrenia (a mental illness that is characterized by disturbances in thought) , and insomnia (trouble falling asleep or staying asleep). During a review of Resident 1's Electronic Medication Administration Record (EMAR), the EMAR indicated a medication scheduled for November 22, 2024, at 0900 (9:00 am), was administered at 11:26 am and documented at 11:32 am by LVN 3. During a review of Resident 2's admission record, Resident 2 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that include dementia (a progressive state of decline in mental abilities), major depressive disorder, and schizophrenia. During a review of Resident 2's EMAR, the EMAR indicated a medication scheduled for November 22, 2024, at 0900, was administered at 10:48 am and documented at 10:50 am by LVN 3. 555368 Page 2 of 3 555368 11/22/2024 Century Villa, Inc 301 Centinela Ave Inglewood, CA 90302

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 3's admission record, Resident 3 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that include epilepsy (a brain disorder that causes seizures, which are episodes of abnormal electrical activity in the brain), schizophrenia, and muscle weakness. During a review of Resident 3's EMAR, the EMAR indicated a medication scheduled for November 22, 2024, at 0900, was administered at 10:06 am and documented at 10:07 am by LVN 3. During a review of Resident 4's admission record, Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that include neuropathy, (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet) anemia (a condition where the body does not have enough healthy red blood cells), and schizophrenia. During a review of Resident 4's EMAR, the EMAR indicated a medication scheduled for November 22, 2024, at 0900, was administered at 11:23 am and documented at 11:24 am by LVN 3. During an interview on 11/22/2024 at 3:00 pm with LVN 3, LVN 3 stated the electronic medical record system they are using is new as of October 8, 2024, and that he is slow documenting medication times. LVN 3 stated medication administration should be done within one hour before or after scheduled time. LVN 3 stated he received training, but feels he needs more but did not mention this to management. During an interview on 11/22/2024 at 4:45 pm with the Director of Nursing (DON), the DON stated the facility switched from paper charting to EMAR on October 8, 20224. DON stated staff was provided twenty-four-hour access to training that can be done at home, in addition to group sessions done in office in a conference room on. The DON stated LVN 3 has not asked for help and that she double checks the staffs work almost every day. DON could not provide documentation for the trainings. During a review of a facility policy entitled Medication Administration dated 2024, indicated administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. During a review of a facility policy entitled Documentation Policy dated 2024, indicated entries must be completed as soon as possible after the care is provided or a significant event occurs. All nursing staff will receive training on proper documentation practices a part of their orientation and ongoing education. 555368 Page 3 of 3