Health inspection·December 9, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure medications with physician-ordered parameters were safely administered for one of three sampled residents (Resident 1) when metoprolol (a medication used to control blood pressure) was given to Resident 1 on 11/16/25 and 11/29/25 despite her vital signs (VS-includes heart rate (pulse) and blood pressure) being outside the physician's parameters and not documented on her medication administration record.These failures potentially contributed to Resident 1 experiencing hypotension, requiring emergency evaluation on 11/18/25, and increasing the risk of further health complications.Findings:A review of Resident 1's Medication Administration Record (MAR) dated 11/1/25 through 11/30/25 indicated the following physician's order: .Metoprolol Tartrate Oral Tablet 25 MG.Give 0.5 tablet via J-Tube [a tube placed directly into the jejunum [middle part of the small intestine] used to give food and medicine] every 8 hours for hypertension [high blood pressure]. Hold if SBP <100 [Systolic Blood pressure-top number in a blood pressure reading-less than 100], HR <60 [Heart Rate [pulse] less than 60]. A review of Resident 1's Weights and Vitals Summary for 11/2025 indicated the following: on 11/16/25 Morning shift BP 126/77, no pulse was recorded. Afternoon shift BP 90/66, pulse 90. Evening shift BP and pulse were not recorded. On 11/29/25 Afternoon shift BP was 89/65.A review of Resident 1's MAR, dated 11/2025 indicated Resident 1's metoprolol was administered to her on 11/16/25 on the morning, afternoon, and evening shift and on 11/29/25 on the afternoon shift. Further review of Resident 1's MAR also revealed a BP reading and a pulse were not documented by an LN on the MAR on 11/16/25 for all three shifts. During a concurrent interview and record review with Licensed Nurse (LN) 1, on 12/9/25 at 11:56 AM, LN 1 reviewed Resident 1's Medication Administration Record [MAR] and Weights and Vitals Summary for 11/2025 and verified that on 11/16/25, metoprolol was administered to Resident 1 during the morning, afternoon, and evening shift even though Resident 1'a blood pressure and pulse were not documented on the MAR. LN 1 verified during a review of Resident 1's Weights and Vitals Summary that on 11/16/25 Resident 1's BP and pulse were outside of the hold parameters and the metoprolol should not have been administered.A review of Resident 1's Progress Notes dated 11/17/25 indicated Resident 1's physician (MD) documented, .Metoprolol.for hypertension. We will continue to maintain the blood pressure log and monitor closely .A review of Resident 1's Progress Notes dated 11/17/25 at 1:25 PM, indicated that LN 4 documented .Pt will be going to a GI (Gastroenterology, digestive system specialist) consult appointment at 2:15 (PM). A review of Resident 1's Progress Notes dated 11/17/25 at 8:56 PM, LN 7 documented, .Resident was sent to.[the] ER [Emergency Room] following a GI appointment.called for an update and was told.they are going to keep [the] resident [Resident 1] d/t [due to] low HR [heart rate] AND LOW BP.A review of Resident 1's ED [Emergency Department] Physician Notes dated 11/18/25 at 1:43 AM, indicated .(Resident 1) presents for evaluation of low blood pressure. She was at the GI clinic.where they found her blood pressure was 75/49. She looked pale and was dizzy so they sent her here (ED) for evaluation.Reason for visit: Weakness or fatigue. Resident 1 was discharged from ED Observation on 11/18/25 at 3: Residents Affected - Few Page 1 of 2 555736 555736 12/09/2025 Golden Sonora Care Center 19929 Greenley Road Sonora, CA 95370

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 57 AM with Diagnoses of Hypotension (low BP) and rapid atrial fibrillation (an irregular, fast heartbeat).During a phone interview with LN 5 on 12/31/25 at 10:28 AM, LN 5 stated that she worked with Resident 1 on 11/16/25 at 10:00 PM (evening shift) when Metoprolol was scheduled for administration. LN 5 stated that the Metoprolol should not be administered if the systolic blood pressure was below 100 and/or the heart rate was below 60. LN 5 stated that administering Metoprolol without checking VS could cause the resident to become hypotensive. During a phone interview with LN 6 on 12/31/25 at 11:00 AM, LN 6 stated that he was the nurse caring for Resident 1 on 11/29/25 at 2:00 PM (afternoon shift) when metoprolol was scheduled for administration. LN 6 confirmed that the physician's order to hold metoprolol for systolic BP less than 100 and/or HR less than 60 was correct and verified that the medication should not be administered when those parameters are not met. LN 6 stated that he typically obtains VS prior to administering metoprolol and was aware that Resident 1's BP frequently ran low. LN 6 stated that the metoprolol should have be held on 11/29/25 for the 2:00 PM dose due to a documented BP of 89/65. LN 6 stated that failure to adhere to the metoprolol hold parameters could result in hypotension.A review of the facility policy titled PREPARATION AND GENERAL GUIDELINES dated 10/17, indicated, .Medications are administered as prescribed in accordance with good nursing principles and practices.Medications are administered in accordance with written orders of the attending physician. 555736 Page 2 of 2