Health inspection·October 27, 2023

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 observation, interview, and record review, the facility failed to ensure the controlled medications for one of one sampled resident (Resident 1) were accounted for during the controlled medication reconciliation. 34 tablets of Resident 1 ' s Clonazepam (Klonopin, a Schedule IV controlled medication used for treatment of panic disorder and epilepsy [seizures]) were unaccounted for during controlled medication reconciliation. This failure had the potential risk for this medication to be used inappropriately and may result in adverse effects to the residents. Findings: During a review Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included epileptic seizures (abnormal electrical brain activity) related to external causes, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and functional quadriplegia (complete inability to move due to severe disability or frailty, not due to spinal cord damage or stroke). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 9/19/23, indicated Resident 1 had the ability to make self-understood and understand others. During a review of Resident 1 ' s history and physical, dated 4/10/23, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's physician orders indicated Resident 1 had an order, dated 7/12/22, to give one tablet of Clonazepam tablet 0.25 mg (milligrams) two times a day for seizures related to external causes. During a review of Resident 1's October 2023 Medication Administration Record indicated Resident 1 did not miss any dose of Clonazepam even after 34 tablets of her Clonazepam were unaccounted for. During an interview on 10/27/23, at 2:20 PM, the Director of Nursing (DON) stated, during the controlled medication reconciliation on 10/25/2023, for the 7 p.m. to 3 p.m. and the 11 p.m. to 7 a.m. shift change, 34 tablets of Resident 1 ' s Clonazepam were missing. The DON stated, they had looked everywhere but could not find the missing medications and they don ' t know how the medications got Page 1 of 2 555737 555737 10/27/2023 Bayshire San Dimas Post-Acute 1740 S San Dimas Ave San Dimas, CA 91773

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few lost and where the medications went. The DON stated, the box of Resident 1 ' s Clonazepam was kept in Medication Cart 1 (Med Cart 1) and she was the only resident receiving Clonazepam at this time. During an observation on 10/27/2023 at 3:05 p.m., the controlled medication reconciliation for the shift changes between the 7 a.m. to 3 p.m. outgoing charge nurse and the incoming 3 p.m. to 11 p.m. charge nurse was observed. The controlled medication count was verified, and no discrepancy was noted for the controlled medication count during this shift change except for the previous discrepancy identified on 10/25/23 for the Clonazepam which was still unaccounted for. During a concurrent observation and interview with the DON on 10/27/2023 at 4:05 p.m., Resident 1 attended a carnival festivity and was not in her room. DON stated, that Resident 1 was okay. Resident 1 was alert and oriented and when interviewed knows she took her 5 p.m. dose of 1 tablet Clonazepam and never missed a dose. During an interview on 10/27/2023 at 4:10 p.m., Licensed Vocational Nurse 1 (LVN 1) stated, on 10/25/2023 she counted and received the controlled medications from the 7 a.m. to 3 p.m. charge nurse, and the controlled medication count was correct. LVN 1 stated, she did not actually count the number of packets for the Clonazepam that was in the box because it looked full. LVN 1 stated, she gave the 5 p.m. dose on 10/25/2023 and the box was full (10 packets with 6 Clonazepam tablets in each packet) because it just got delivered yesterday. LVN 1 stated, it was during the controlled medication reconciliation count with the incoming 11 p.m. to 7 a.m. shift charge nurse on 10/25/2023 at around 11:30 p.m., when they found out that 34 tablets of Clonazepam were missing. LVN 1 stated, that they check the drawers of the med cart and it was nowhere to be found. LVN 1 stated that she notified the DON around 11:45 p.m. when they couldn ' t find the missing medication. LVN 1 stated, there were no residents discharged and no medications were sent to the DON to be discarded during her shift. LVN 1 stated, her mistake was she did not see the actual medications that was being counted because she was in front of the logbook and the incoming nurse was behind her and in front of the narcotics drawer. During a review of the facility ' s policy and procedure revised on November 2022, titled, Controlled Substances, indicated that the nurse coming on duty and the nurse going off duty make the count together and document and report discrepancies to the Director of Nursing. 555737 Page 2 of 2