Health inspection·June 7, 2019

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure medications were kept safe and secure for 2 of 12 sampled residents (Resident 16 and Resident 21) and 3 non-sampled residents (Resident 3, Resident 32, and Resident 33) when residents medications were on top of the overbed table mixed with food condiments and personal items. Residents Affected - Some These failures had increased residents risks for unsafe medication storage and food hazards. Findings: 1. Resident 16 was admitted in 2015. A review of the physician's order, dated 4/6/15 indicated, [Brand name, antifungal powder that absorbs moisture while helping to prevent skin irritation] topically to folds of bilateral breasts daily as needed for redness. A review of the physician's order dated 4/6/15, indicated Resident 16 has the capacity to make health care decisions. Documentation regarding Self-Medication Administration Assessment was requested from Licensed Nurse 2 (LN 2), but no document was provided. During an observation and interview on 6/5/19 at 11:54 a.m., on 6/6/19 at 2 p.m. and at 4:22 p.m., there was a hard plastic bottle labeled [Brand Name, treatment powder] on top of the over-bed table mixed with food condiments and personal items. Resident 16 was asked, What do you use this powder for? Resident 16 looked at the plastic bottle and stated, I don't know what is that bottle for. During an observation and interview on 6/7/19 at 10:32 a.m., LN 2 acknowledged the observation and stated, That plastic bottle was a powder treatment medication . it should not be in the over-bed table .it should be kept in the treatment cart. 2. Resident 21 was admitted in 2016 with diagnoses which included allergic rhinitis (allergic response to specific allergens). A review of the physician's order dated 12/9/17 indicated, [Brand Name for nasal spray] 0.05 mg [milligram, unit of measurement]/1 Actuation Spray, ****May keep at bedside**** 1 spray nasal Every Day each nostril for Allergic Rhinitis. A review of the physician's order dated 7/18/18 indicated, [Brand name, eye drops for eye (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 4 Event ID: 555698 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 555698 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/07/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Barton Hospital D/P Snf 2170 South Avenue South Lake Tahoe, CA 96150 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)