Health inspection·March 21, 2024

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for one of three sampled residents (Resident 1) when there was no documentation that licensed nurses notified the physician that Resident 1 did not receive multiple medications. Failure to notify the physician had the potential to result in additional orders not being received and carried out as needed. Residents Affected - Few Findings: Review of Resident 1 ' s medical record indicated Resident 1 was admitted to the facility on [DATE] at 9:20 p.m. Resident 1 had diagnoses including osteomyelitis (a bone infection), Parkinson ' s Disease (a disorder of the nervous system that affects movement), dementia (a mental disorder caused by brain disease or injury), duodenal ulcer (a sore in part of the intestine), and gout (a type of arthritis [joint tenderness and swelling] that causes pain and stiffness). Review of Resident 1 ' s medication administration record (MAR), dated 1/2024, indicated Resident 1 was scheduled to receive the following medications: 1.) Amlodipine (medication used to treat high blood pressure) 5 milligrams (mg, unit of dose measurement) to be administered at 9:00 a.m.; 2.) Ascorbic acid (vitamin C) 250 mg to be administered at 9:00 a.m.; 3.) Rytary (medication used to treat Parkinson ' s Disease) 48.7 mg– 195 mg 2 capsules to be administered at 5:00 a.m.; 4.) Colchicine (medication used to treat gout) 0.6 mg to be administered at 9:00 a.m.; 5.) Flector 1.3% transdermal patch (pain medication applied to the skin) to be applied at 9:00 a.m.; 6.) Febuxostat (medication used to treat gout) 40 mg to be administered at 9:00 a.m.; 7.) Pantoprazole (medication that reduces stomach acid) 40 mg to be administered at 11:30 a.m.; 8.) Polyethylene glycol (medication used to prevent constipation) 17 grams (gm, unit of dose measurement) to be administered at 9:00 a.m.; 9.) Sucralfate (medication used to treat ulcers in the intestines) 100 mg per milliliter (mg/ml, unit of dose measurement) to be administered at 9:00 a.m.; and 10.) Valproic acid (medication used to treat seizures but can also be used as a mood stabilizer) 250 mg/ml to be administered at 2:00 p.m. Further review of Resident 1 ' s MAR indicated for the above scheduled medications, the documentation was highlighted in grey on 1/24/24. The last four pages of the MAR indicated for amlodipine 5mg, ascorbic acid 250 mg, Rytary 48.75 – 195 mg, colchicine 0.6mg, Flector 1.3% transdermal patch, and febuxostat 40 mg, the documentation was highlighted in grey on 1/24/24 because the medications were not administered to Resident 1. The MAR did not indicate why the documentation was highlighted in grey for pantoprazole 40 mg, polyethylene glycol 17 gm, sucralfate 100 mg/ml, and valproic acid 250 mg/ml. Review of Resident 1 ' s Daily Skilled Progress Notes, dated 1/24/24, indicated the facility was, Page 1 of 4 555547 555547 03/21/2024 The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032

F 0684 Waiting for most medications to be delivered from pharmacy. Level of Harm - Minimal harm or potential for actual harm During a telephone interview with licensed nurse A (LN A) on 3/20/24 at 11:29 a.m., LN A verified she did not administer some of Residents Affected - Few Resident 1 ' s medications because they were not available in the facility. LN A stated she did not remember whether or not she notified the physician about the medications Resident 1 did not receive. LN A stated if she did notify the physician, it would be documented in her notes. During an interview and concurrent record review with LN B on 3/20/24 at 11:53 a.m., LN B stated if a resident did not receive medications, the nurse should inform the physician, await and follow the physician's orders, and document this in the medical record. LN B reviewed Resident 1 ' s medical record and confirmed that on 1/24/24, there were multiple medications not administered because the facility was waiting for the pharmacy delivery. LN B confirmed there was no documentation that indicated the physician was notified about the medications Resident 1 did not receive. During an interview with administrative staff E (AS E) on 3/21/24 at 12:11 p.m., AS E stated the facility did not have a specific policy regarding physician notification. AS E acknowledged that notifying the physician about medications not received was a basic standard of nursing practice. 555547 Page 2 of 4 555547 03/21/2024 The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032

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 administer medications as ordered for one of three sampled residents (Resident 1) because the medications were not available in the facility. This failure had the potential to compromise Resident 1 ' s health and well-being. Findings: Review of Resident 1's medical record indicated Resident 1 was admitted to the facility on [DATE] at 9:20 p.m. Resident 1 had diagnoses including osteomyelitis (a bone infection), Parkinson ' s Disease (a disorder of the nervous system that affects movement), dementia (a mental disorder caused by brain disease or injury), duodenal ulcer (a sore in part of the intestine), and gout (a type of arthritis [joint tenderness and swelling] that causes pain and stiffness). Review of Resident 1's medication administration record (MAR), dated 1/2024, indicated Resident 1 was scheduled to receive the following medications: 1.) Amlodipine (medication used to treat high blood pressure) 5 milligrams (mg, unit of dose measurement) to be administered at 9:00 a.m.; 2.) Ascorbic acid (vitamin C) 250 mg to be administered at 9:00 a.m.; 3.) Rytary (medication used to treat Parkinson ' s Disease) 48.7 mg– 195 mg 2 capsules to be administered at 5:00 a.m.; 4.) Colchicine (medication used to treat gout) 0.6 mg to be administered at 9:00 a.m.; 5.) Flector 1.3% transdermal patch (pain medication applied to the skin) to be applied at 9:00 a.m.; 6.) Febuxostat (medication used to treat gout) 40 mg to be administered at 9:00 a.m.; 7.) Pantoprazole (medication that reduces stomach acid) 40 mg to be administered at 11:30 a.m.; 8.) Polyethylene glycol (medication used to prevent constipation) 17 grams (gm, unit of dose measurement) to be administered at 9:00 a.m.; 9.) Sucralfate (medication used to treat ulcers in the intestines) 100 mg per milliliter (mg/ml, unit of dose measurement) to be administered at 9:00 a.m.; and 10.) Valproic acid (medication used to treat seizures but can also be used as a mood stabilizer) 250 mg/ml to be administered at 2:00 p.m. Further review of Resident 1 ' s MAR indicated for the above scheduled medications, the documentation was highlighted in grey on 1/24/24. The last four pages of the MAR indicated for amlodipine 5mg, ascorbic acid 250 mg, Rytary 48.75 – 195 mg, colchicine 0.6mg, Flector 1.3% transdermal patch, and febuxostat 40 mg, the documentation was highlighted in grey on 1/24/24 because the medications were not administered to Resident 1. The MAR did not indicate why the documentation was highlighted in grey for pantoprazole 40 mg, polyethylene glycol 17 gm, sucralfate 100 mg/ml, and valproic acid 250 mg/ml. Review of Resident 1 ' s Daily Skilled Progress Notes, dated 1/24/24, indicated the facility was, Waiting for most medications to be delivered from pharmacy. During a telephone interview with licensed nurse A (LN A) on 3/20/24 at 11:29 a.m., LN A verified she did not administer some of Resident 1 ' s medications because they were not available in the facility. LN A stated she was not aware the medications were unavailable until it was time to administer them to Resident 1. LN A added if she had known beforehand that the medications had not yet arrived, she would have called the pharmacy to follow up regarding the delivery. 555547 Page 3 of 4 555547 03/21/2024 The Terraces of Los Gatos 800 Blossom Hill Road Los Gatos, CA 95032

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview and concurrent record review with LN B on 3/20/24 at 11:53 a.m., LN B stated if a resident is admitted to the facility at 9:20 p.m., the night shift nurse should monitor whether or not the resident ' s medications arrive from the pharmacy. LN B explained if the medications do not arrive in a timely manner, the nurse should contact the pharmacy to follow up on the delivery. LN B added that the nurse could request a STAT (rushed) delivery of the medications if they do not arrive in a timely manner. LN B reviewed Resident 1 ' s medical record and confirmed that on 1/24/24, there were multiple medications not administered because the facility was waiting for the pharmacy delivery. LN B confirmed there was no documentation that indicated the nurses followed up with the pharmacy regarding the delivery of Resident 1 ' s medications. LN B also confirmed there was no documentation that indicated the nurses requested a STAT delivery of Resident 1 ' s medications. During a telephone interview with pharmacy staff C (PS C) and pharmacy staff D (PS D) on 3/20/24 at 2:40 p.m., they reviewed the pharmacy records and PS C stated the pharmacy received Resident 1 ' s faxed medication orders at 10:30 p.m. on the day of admission. PS C stated these medications should have been on the delivery that left the pharmacy at 5:00 a.m. the following morning. PS D stated Resident 1 ' s medications were not on the 5:00 a.m. delivery, but they were on the next delivery that went out at 1:00 p.m. PS D stated the facility could have asked for a STAT delivery of Resident 1 ' s medications, but confirmed there was no documentation in the pharmacy record that indicated the facility did this. When asked why Resident 1 ' s medications did not make it onto the 5:00 a.m. delivery, PS D stated more research needed to be done to determine the reason. Review of a follow-up email from PS D, dated 3/20/24, indicated the pharmacy received Resident 1 ' s faxed medication orders on 1/23/24 at 10:13 p.m. However, the facility did not electronically transmit the medication orders to the pharmacy until 1/24/24 at 4:06 a.m. (less than an hour before the 5:00 a.m. delivery). The email from PS D indicated the normal procedure was for the pharmacy to process medication deliveries using the electronically transmitted orders. PS D ' s email further indicated, Unfortunately, they missed the run [delivery] at 5am, but were place on the next run leaving at 1pm. I don ' t see any notes from the facility requesting a STAT delivery. The facilitys policy titled Administering Medications, revised 4/2019 indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). The facilitys policy titled Medication Ordering and Receiving From Pharmacy Provider, dated 1/2023 indicated, Medications and related products are received from the provider pharmacy on a timely basis. The policy further indicated, Inform the pharmacy of the need for prompt delivery. 555547 Page 4 of 4