Health inspection·August 16, 2019

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 observations, interviews and record reviews, the facility failed to obtain medication for one of four sampled residents (Resident 48) when Isosorbide Mononitrate ER (medication used for heart related chest pain) was not available to administer to Resident 48. The failure to obtain and administer ordered medication had the potential to delay treatment and prolong healing. Findings: During a review of Resident 48's physician's order indicated starting 7/26/19 Isosorbide Mononitrate 60 milligrams should be administered once a day. During concurrent medication administration observation and interview on 8/13/19 at 9:52 a.m., RN 1 did not administer Isosorbide Mononitrate ER 60 milligrams (mg) to Resident 48. RN 1 stated there was no available medicine to administer. During concurrent observation and interview on 8/13/19 at 10:19 a.m., RN 1 together with Licensed Vocational Nurse 1 (LVN 1) opened the drug dispensing machine and Isosorbide Mononitrate ER 60 mg was not available. During an interview with Director of Nursing (DON) on 8/13/19 at 1:03 p.m., the DON stated the charge nurses reorder routine medicines electronically or by sending the reorder stickers to the pharmacy. The DON also stated reordering takes place when seven to eight pills remain in the supply to provide adequate time for delivery. Page 1 of 4 555684 555684 08/16/2019 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to ensure medication error rate of below five percent (%). When: Residents Affected - Few 1. Licensed Vocational Nurse 2 (LVN 2) administered Isosorbide Mononitrate ER (medication used for heart related chest pain) beyond the ordered time frame to Resident 48. 2. Registered Nurse 1 (RN 1) administered regular Aspirin to Resident 48 when the order was Aspirin EC (enteric coated-medicine dissolves in the small intestine instead of stomach to prevent stomach upset) delayed release. These deficient practices placed Resident 48 at risk of developing complications related to error in medication administration. Findings: 1. During concurrent medication administration observation and interview on 8/13/19 at 9:52 a. m., RN 1 did not give Isosorbide Mononitrate ER 60 milligrams (mg) to Resident 48. She stated there was no available medicine to give. During an interview with RN 1 on 8/13/19 at 12:46 p. m., she stated she called pharmacy and was told that Isosorbide will be delivered on 8/13/19. She also stated she called the doctor for Resident 48 and notified that medicine was not available and will be delivered on 8/13/19. She said the doctor gave an order to give Isosorbide one time when delivered. Review of Medication Administration Record (MAR) dated 8/14/19, it indicated Isosorbide Mononitrate ER tablet extended release 24 hour 60 milligrams (mg) give one tablet by mouth one time only for Anti-angina (chest pain) until 8/13/19 23:59. MAR also indicated that Isosorbide was given by LVN 2 on 8/14/19 at 0024. 2. During medication administration observation on 8/13/19 at 9:52 a. m., RN 1 administered regular Aspirin (chewable) to Resident 48. Review of electronic Physician's Order indicated Aspirin EC Tablet Delayed Release 81 mg, give 81 mg by mouth one time a day for clot (clump of blood) prevention. 555684 Page 2 of 4 555684 08/16/2019 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0803 Level of Harm - Minimal harm or potential for actual harm Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Based on observation, interview and record review, the facility failed to follow the planned menu when less than stated amount of breaded fish or turkey patty was served to residents receiving regular diets. Residents Affected - Some This failure resulted in residents not getting the prescribed amount of protein for lunch and the potential for weight loss and malnutrition. Findings: Review of the undated document titled Cooks Spreadsheet Summer Menus Week 2 indicated the facility was to serve 3-4 oz of breaded fish to residents on regular diet at lunch on 8/12/19. During a trayline observation and concurrent interview with the Director of Food and Nutrition Services (DFNS) and [NAME] 1 on 8/12/19 at 11:45 a.m., after all the trays were plated, a serving portion of the breaded fish and the turkey patty were weighed by [NAME] 1. The DFNS and [NAME] 1 confirmed one piece of the breaded fish weighed 2 ounce (oz- a unit of measurement) and one piece of the turkey patty weighed 1.75 oz. Both the DFNS and [NAME] 1 confirmed the fish and the turkey weighed less than the required amount of protein on the planned menu. [NAME] 1 stated she weighed the turkey patties before she cooked them. The DFNS stated the proteins should weigh 3-4 oz according to the spreadsheet. During an interview with Resident 30 on 8/12/19 at 1:30 p.m., Resident 30 stated the patty was very small and would have liked more. During an interview with the Registered Dietitian (RD) on 8/13/19 at 1:10 p.m., the RD stated the dietary spreadsheet/menu should be followed. RD also stated [NAME] 1 should have served two pieces of turkey patties. RD further stated the facility must provide the required amount of protein to the residents. 555684 Page 3 of 4 555684 08/16/2019 Legacy Post Acute Care 1790 Muir Road Martinez, CA 94553

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation and interviews, the facility failed to ensure infection control practice was implemented during medication administration to one of four sampled residents (Resident 65). When Registered Nurse 1 (RN 1) brought the whole bottle of probiotics (live bacteria that are good for the digestive system) inside Resident 65's room. Residents Affected - Few This deficient practice placed residents at risk for contracting infection through medication administration. Findings: During medication administration observation on 8/13/19 at 8:44 a. m., RN 1 brought the whole bottle of previously opened probiotics inside Resident 65's room and placed it on the bedside table. During an interview with RN 1 on 8/13/19 at 9:10 a. m., she stated she shouldn't have brought the whole bottle of probiotics inside Resident 65's room. She also stated it is okay to put it back inside the medication cart but she decided to discard the whole bottle. She also mentioned she will find out how to discard the bottle of probiotics. During an interview with Director of Nursing (DON) on 8/13/19 at 12:50 p. m., she stated the bottle of probiotics shouldn't have been brought inside Resident 65's room as standard practice. She also stated that wasted or discontinued medicines could be discarded in the sharps container or inside the medication room where there's a bin for wasted/discontinued medicines. 555684 Page 4 of 4