Health inspection·June 25, 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure on narcotic (pain medication) count, narcotic dispensing, and storage for one of three sampled residents (Resident 1). This failure resulted in missing narcotic medications and had the potential to affect Resident 1's pain control.During a review of the facility email (FEM), dated 6/24/25, the FEM indicated Resident 1's narcotic medications (morphine - a narcotic pain medication) were placed into the medication room on 6/11/25 but were not double locked in the narcotics drawer. Licensed Vocational Nurse (LVN) 1 accessed Resident 1's home medications during her evening shift (7 p.m. to 7:30 a.m.) to administer one morphine ER (extended release - medication that is released into the body over a period of time) 15 mg (milligram - a unit of measurement) pill to Resident 1. The FEM indicated, The (Resident 1's morphine) should not have been used, and the staff should have notified the provider (medical doctor) to see if an alternative pain medication . could be used to control (Resident 1's) pain. The FEM indicated, (The facility) received a new (admission) from Acute (hospital) on 6/11/25 (at 1:05 p.m.) . Resident (1) came over with a large bag of ‘at home' Narcotics . (Resident 1's) at home medications sheet (a sheet that keeps count of medications) was folded and placed in the (Resident 1's) bag. The bag was placed in the (medication) room by (Registered Nurse - RN 1). (RN 1's) name is printed as the (receiving) Nurse. However (sic) no signature was on the sheet. When I (unknown person) came on shift today I noticed the bag sitting on the med room counter and (unknown person) mentioned that (LVN 1) used (Resident 1's) at home (medications) instead of pulling from the Ekit (a container that holds different medications in case of emergency). The (medications) were counted and it was noted that the Morphine 15mg tabs were 67 in one bottle 1 used on (LVN 1's) shift (totaling 68) and the count on acute (hospital) care sheet stated 44 + 39 (83). That would make a discrepancy of 15 (pills) short. The (Acute Care Nurse - ACN) and (Facility Pharmacist - FP) from acute (hospital) should have counted before (Resident 1) left acute (hospital) and then counted with the (facility) receiving (RN 1).During an interview on 6/25/25 at 11:47 with Director of Nursing (DON), DON stated Resident 1 was admitted to the facility from the acute hospital (the facility and acute hospital share the same building) on 6/11/25. Resident 1's home medications including morphine were brought in by family and counted by the acute hospital staff. DON stated when Resident 1 was discharged from the acute hospital portion of the facility, RN 1 (facility RN) picked up Resident 1 from the acute hospital (via gurney) and was given Resident 1's home narcotic medications (morphine) from ACN. DON stated a count of Resident 1's narcotics medications was not done during the exchange from acute care to the facility. DON stated RN 1 placed Resident 1's narcotic medications (morphine) into the facility medication room but not stored in a locked area as it should have been. DON stated a count of Resident 1's narcotic medication (morphine) was not done until the next day (6/12/25). DON stated when Resident 1's narcotic medications were counted on 6/12/25 by Assistant Director of Nursing Page 1 of 3 555517 555517 06/25/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (ADON), 15 morphine ER 15 mg pills were found to be missing from the 83 pills she had brought in from home. During an interview on 6/25/25 at 12:15 p.m. with ADON, ADON stated on 6/12/25 she counted Resident 1's narcotic medications (morphine) in the facility medication room. ADON stated Resident 1's narcotic medications were on the counter and not double locked as they should have been. ADON stated she counted the medications and found 15 morphine ER 15 mg pills were missing. ADON stated she called FP, and FP verified 15 morphine ER 15 mg pills were missing. During a review of Resident 1's admission RECORD (AR), dated 6/25/25, the AR indicated, Resident 1 was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (COPD - a group of lung conditions that make it hard to breathe), major depressive disorder (a serious mental health condition characterized by feelings of sadness, loneliness, and hopelessness), wedge compression fracture (a type of spinal break in bone of unspecified where part of the bone collapses or [NAME] in) of lumbar vertebra (lower back), and cachexia (condition characterized by the loss of muscle and fat mass). During a review of Resident 1's Minimum Data Set (MDS) Assessment (a standardized assessment to evaluate a resident's functional abilities and healthcare needs), dated 6/19/25, under the section titled, Brief Interview for Mental Status (BIMS - an assessment of cognition [how well a person thinks, remembers, and learns]), the BIMS score was 15 (cognition intact).During an interview on 6/25/25 at 12:32 p.m. with Resident 1, Resident 1 stated she was taking narcotic medication to control pain from COPD and a fracture (broken bone) in her spine. During an interview on 6/25/25 at 1:16 p.m. with Risk Manager (RM), RM stated during Resident 1's transfer from the acute hospital to the facility ACN and RN 1 did not conduct a narcotic count of Resident 1's morphine. RM stated Licensed Vocational Nurse (LVN) 1 had taken over care for Resident 1 in the evening and a narcotic count of Resident 1's morphine was not done. RM stated LVN 1 used one of Resident 1's home morphine ER 15 mg to treat a complaint of pain (During the night of 6/11/25 and 6/12/25, no time specified). RM stated LVN 1 should not have used Resident 1's morphine medication from home. RM stated a count of narcotics to ensure accuracy should have been done per policy, the narcotic medications should have been double locked and Resident 1's home medication of morphine ER 15 mg should not have been used. During an interview on 7/2/25 at 11:05 a.m. with RN 1, RN 1 stated on 6/11/25 she went to the acute hospital to pick up Resident 1 from ACN. RN 1 stated she did not conduct a count of Resident 1's narcotic medications with ACN. RN 1 stated when she brought Resident 1 to the facility, she had placed Resident 1's narcotic medications in the facility medication room but did not lock the medication in a secure area. RN 1 stated that night (6/11/25) Resident 1's care was transferred to LVN 1, but a narcotic count was not done. During an interview on 7/21/25 at 2:29 with LVN 1, LVN 1 stated she could not recall doing a narcotic count of Resident 1's home medications when she took over her care on 6/11/25. LVN 1 stated she did give Resident 1 morphine ER 15 mg from Resident 1's home medication (During the night of 6/11/25 and 6/12/25, no time specified) due to a complaint of pain but should not have done that. During a review of Resident 1's Patient Home Medications (PHM), dated 5/25/25, the PHM indicated Resident 1 had 83 morphine ER 15 mg pills brought in from home. During a review of the facility's policy and procedure (P&P) titled, Controlled Substance Distribution and Security, dated 4/27/15, the P&P indicated, The storage, distribution and accounting of controlled substances will be done in accordance with all federal and state laws and standards of professional practice. Any controlled substance prescription dispensed to a patient within the SNF shall be issued a count sheet capable of recording each administration of all the doses dispensed. When an actual/physical controlled substance count does not match a perpetual count on a count sheet through routine use of the count sheet or random audit and the discrepancy cannot be explained on investigation, the event will be reported to the Director of 555517 Page 2 of 3 555517 06/25/2025 Kern Valley Healthcare District Dp Snf 6412 Laurel Ave Lake Isabella, CA 93240

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Nursing as well as the facility risk management department. Lost or missing controlled substances shall be reported to the California State Board within 30 days of discovery. The product, strength and quantity shall be reported. All controlled substances will be stored utilizing double locked security. Only licensed personnel or authorized personnel under the direct supervision of licensed personnel shall have access to controlled substances stored within the (facility).On 7/18/25 at 3:52 p.m. a request for the facility's P&P on narcotic count during change of shifts was made and had not been made available and/or found at the time of this write up. 555517 Page 3 of 3