Health inspection·February 5, 2026

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 ensure residents' controlled medications (medications that can cause physical and mental dependence and are regulated by the Drug Enforcement Administration) were secured in the facility's medication carts. Specifically, controlled substances, including Individual Patient's Narcotic Records (IPNR), were removed from the cart without the licensed nurses' (LNs) knowledge and were left unaccounted for 10 of 10 residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). This had the potential for affected residents' medication to not being available in the event they were needed. There were no missed doses for the affected residents.Findings:On 12/12/25, the Department received a facility report incident related to pharmaceutical services. On 1/7/26, an unannounced onsite visit to the facility was conducted. A review of the residents' record were as follows.1.Resident 1 was admitted to the facility on [DATE], with diagnoses which included liver cancer, per the facility's admission Record. A review of Resident 1's physician order dated 11/11/25 indicated, Tramadol 50 mg tablet 1-2 tablets for moderate and severe pain as needed (PRN) every 6 hours.A review of the pharmacy packing slip dated 11/11/25 indicated, the facility licensed nurse (LN) received 30 tablets of Tramadol HCL 50 mg (milligrams).A review of Resident 1's Individual Patient's Narcotic Record (IPNR) indicated, there were 26 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 2. Resident 2 was admitted to the facility on [DATE], with diagnoses which included chronic back pain, per the facility's admission Record. A review of Resident 2's physicians order dated 8/22/25 indicated, Hydrocodone- Acetaminophen 10-325 mg tablet, give 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain. In addition, the physicians order dated 9/15/25 indicated, Oxycontin 10 mg, give 1 tablet by mouth twice a day for pain management.a. A review of the pharmacy packing slip dated 11/5/25 indicated that the facility's licensed nurse (LN) received 60 tablets of Oxycodone - Acetaminophen (Percocet) 10-325 mg.A review of Resident 2's Individual Patient's Narcotic Record (IPNR) indicated there were 23 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover).b. A review of the pharmacy packing slip dated 11/5/25 indicated that the facility's licensed nurse (LN) received 8 tablets of Oxycodone - Acetaminophen (Percocet) 10-325 mg.A review of Resident 2's Individual Patient's Narcotic Record (IPNR) indicated there were 5 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover).c. A review of the pharmacy packing slip dated 11/28/25 indicated that the facility's licensed nurse (LN) received 28 Oxycontin ER 10 mg. tablets. A review of Resident 2's Individual Patient's Narcotic Record (IPNR) indicated there were 5 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 3. Resident 3 was admitted to the facility on [DATE], with diagnoses which included chronic low back pain - intractable, per the facility's admission Record. A review of Resident 3's physicians Page 1 of 4 555754 555754 02/05/2026 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some order dated 10/26/25 indicated, Oxycodone 10 mg., give 1 tablet by mouth every 6 hours PRN (as needed) for pain.A review of the pharmacy packing slip dated 12/3/25 indicated that the facility's licensed nurse (LN) received 30 tablets of Oxycodone HCL(IR) 10 mg.A review of Resident 3's Individual Patient's Narcotic Record (IPNR) indicated there were 0 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 4. Resident 4 was admitted to the facility on [DATE], with diagnoses which included chronic venous hypertension with ulcer of left and right lower extremities (a severe, chronic, and often painful open skin lesion caused by sustained high pressure in the leg veins), per the facility's admission Record. A review of Resident 4's physicians order dated 10/1/25 indicated, Oxycodone 5 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain.There was no packing pharmacy packing slip included in the documentation.A review of Resident 4's Individual Patient's Narcotic Record (IPNR) indicated, there were 17 tablets dispensed by the pharmacy with 5 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 5. Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic vascular disorders of intestines- ischemic colitis (reduced blood flow to the large intestine (colon) causes inflammation and damage due to lack of oxygen and causes ongoing or recurring stomach pain, diarrhea, and potential tissue damage over time.), per the facility's admission Record. A review of Resident 5's physicians order dated 8/4/25 indicated, Oxycodone 15 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for epigastric pain.A review of the undated pharmacy packing slip indicated, the facility received 58 tablets of Oxycodone HCL(IR) 15 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) was received. A review of Resident 5's Individual Patient's Narcotic Record (IPNR) indicated there were 2 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 6. Resident 6 was re- admitted to the facility on [DATE], with diagnoses which included chronic pain syndrome, per the facility's admission Record. A review of Resident 6's physicians order dated 11/27/25 indicated, Oxycodone 5 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for mild pain. And 15 mg., 3 tablets by mouth every 4 hours PRN for severe pain.A review of the undated pharmacy packing slip indicated, the facility received 90 tablets of Oxycodone HCL(IR) 5 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) 5 mg. was received. A review of Resident 6's Individual Patient's Narcotic Record (IPNR) indicated there were 90 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 7. Resident 7 was readmitted to the facility on [DATE], with diagnoses which included end stage renal disease (kidney failure), per the facility's admission Record. A review of Resident 7's physicians order dated 9/24/25 indicated, Oxycodone 5 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for pain management.A review of the undated pharmacy packing slip indicated, the pharmacy dispensed 30 tablets of Oxycodone HCL(IR) 5 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) 5 mg. was receivedA review of Resident 7's Individual Patient's Narcotic Record (IPNR) indicated there were 7 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). 8. Resident 8 was readmitted to the facility on [DATE], with diagnoses which included cervical disc disorder (a wear and tear condition where the soft, rubbery cushions (discs) between your neck bones (vertebrae) break down, dry out, or bulge, often causing chronic neck pain, stiffness, and nerve pain that radiates into the shoulders or arms) , per the facility's admission Record. A review of Resident 8's physicians order dated 6/18/25 indicated, Oxycodone 20 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for pain.A review of the undated pharmacy packing slip indicated, 555754 Page 2 of 4 555754 02/05/2026 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the pharmacy dispensed 30 tablets of Oxycodone HCL(IR) 5 mg. There was no licensed nurse (LN) signature to reflect 30 tablets of Oxycodone HCL(IR) 5 mg. was received.A review of Resident 8's Individual Patient's Narcotic Record (IPNR) indicated there were 0 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover) and missed signatures of licensed nurses. 9. Resident 9 was admitted to the facility on [DATE], with diagnoses which included bilateral osteoarthritis of knee (chronic wear-and-tear disease where the protective cartilage cushioning the ends of bones breaks down over time, causing pain, swelling, and stiffness.), per the facility's admission Record. A review of Resident 9's physicians order dated 11/15/25 indicated, Oxycodone 5 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain and 10 mg I tablet by mouth every 6 hours PRN for severe pain.A review of the pharmacy packing slip dated 11/15/25 indicated, the pharmacy dispensed 11 tablets of Oxycodone HCL(IR) 10 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) 10 mg. was received.A review of Resident 9's Individual Patient's Narcotic Record (IPNR) indicated there were 5 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover.A review of the pharmacy packing slip dated 11/15/25 indicated, the pharmacy dispensed 16 tablets of Oxycodone HCL(IR) 5 mg. There was no licensed nurse (LN) signature to reflect the Oxycodone HCL(IR) 5 mg. was received.A review of Resident 9's Individual Patient's Narcotic Record (IPNR) indicated there were 2 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover 10. Resident 10 was admitted to the facility on [DATE], with diagnoses which included fracture of left fibula and fibula (leg fracture), per the facility's admission Record. A review of Resident 9's physicians order dated 11/25/25 indicated, Oxycodone - acetaminophen 5-325 mg., give 1 tablet by mouth every 4 hours PRN (as needed) for moderate pain.A review of the undated pharmacy packing slip indicated the pharmacy dispensed 16 tablets of Oxycodone -Acetaminophen 5-235 mg. There was no licensed nurse (LN) signature indicated the pharmacy dispensed 16 tablets of Oxycodone -Acetaminophen 5-235 mg.A review of Resident 10's Individual Patient's Narcotic Record (IPNR) indicated there were 4 tablets left in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover On 1/7/26 at 10:50 A.M., an interview was conducted with the Administrator (ADM) and the Director of Nursing (DON). The ADM stated on 12/19/25 the facility's interim DON received a call from another skilled nursing facility (SNF) about a licensed nurse working through a staffing agency who was involved in a drug diversion case. During the investigation of the other SNF, original narcotic sheets and medication bubble packets were discovered and traced back to their facility. The ADM further stated the involved licensed nurse was immediately removed from the schedule and her account was deactivated.On 1/7/26 at 11:15 A.M., an interview was conducted with the DSD (Director of Staff development). The DSD stated if the pharmacy brought controlled meds to the nursing station, the receiving LN signed the pharmacy packing list, the white form stayed in the facility and the yellow copy goes to pharmacy. The DSD stated staff were trained for shift-to-shift counts. Each nurse counted the number of medications cards and both staff verified and signed. The DSD stated the count matched the quantity of the medications from the CDR and from the med bubble card. On 1/7/26 at 11:40 A.M., an interview was conducted with licensed nurse (LN) 1. LN 1 stated controlled meds were counted before and after the shift. LN 1 stated the outgoing LN reviewed the narcotic count sheet by reading the resident's name, name of the controlled meds, dosage and number of the drugs remained in the count sheet. The incoming LN reviewed the med bubble pack by checking the resident's name, drug name, dosage, and the number of drugs left in the med bubble pack. After all controlled meds are administered from the med bubble pack, the controlled 555754 Page 3 of 4 555754 02/05/2026 Village Square Healthcare Center 1586 W. San Marcos Blvd San Marcos, CA 92078

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some narcotic sheet (CDR) goes to medical records, and the med bubble pack goes to the shredder. LN 1 stated the Nursing supervisor, or DON will be informed if there was a discrepancy during the count of the narcotic. On 1/7/26 at 12 noon, an interview was conducted with LN 2. LN 2 stated that each station had a narcotic binder. The incoming LN counted the medication bubble packs from the drawer. Both incoming and outgoing LN signed the narcotic binder. The outgoing LN read out the resident's name, name of controlled drug, dosage and the number of medications remained from the CDR. The incoming nurse reviewed the meds-controlled bubble pack, name of resident, name of the drug, and the number of meds left in the med bubble pack. LN 2 stated, when new refills were received, the receiving LN was required to document in the narcotic binder the number of cards received, but not the quantity of pills received. LN 2 stated that she worked with LN from the staffing agency regularly 2 stated if there's discrepancy from the count sheet, the nursing Supervisor should be notified. On 1/7/26 at 12:50 P.M., an interview was conducted with LN 3. LN 3 stated that controlled drugs were being counted every beginning of the shift between the incoming and the outgoing LN. The LN signed the narcotic binder. On 1/7/26 at 1:15 P.M., an interview was conducted with the ADM and DON. The ADM and the DON both stated they were unaware that there were discrepancy. The ADM stated after knowing the issue, they have started their own investigation and updated the controlled medications reconciliation policy and procedure. A review of the facility's policy titled, Drug Diversion, dated 12/19, indicated .Drug diversion (theft) is prohibited. Suspected drug diversion will be investigated and in the event that substantial evidence supports a belief that diversion has occurred, appropriate disciplinary and reporting actions will be taken. A review of the undated facility's policy, titled, Medication Destruction, indicated .to destroy medications in accordance with state and federal guidelines. A review of the facility's policy dated 1/20, titled, Ordering and receiving Controlled medications, indicated .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by the state law. the pharmacy or nursing care center prepares and individual resident controlled substance record. this log is placed in the MAR or narcotic book to be counted every shift. 555754 Page 4 of 4