Health inspection·June 25, 2024

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the medical records for three of eight sampled residents (Residents 2, 3, and 8) were complete and accurate. * The facility failed to ensure the licensed nurse documented the blood sugar levels and medications administered to Resident 2 in the MAR. * The facility failed to ensure the licensed nurse documented the blood sugar levelsand insulin medication administered to Resident 3 in the MAR. * The facility failed to ensure the licensed nurse documented the initials in the MAR when Resident 8's medications were administered. These failures had the potential for the residents' care needs not being met as their medical information were inaccurate and incomplete. Findings: Review of the facility's P&P titled Specific Medication Administration Procedures dated 10/2019, showed to obtain and record any vital signs or other monitoring parameters ordered or deemed necessary prior to medication administration; and after the administration of medication, return to the cart, replace medication container, and document the administration in the MAR or TAR. Review of the facility's P&P titled Obtaining a Fingerstick Glucose Level (undated) under the section for Documentation showed the person performing this procedure should record the following information in the resident's medical record: - the date and time the procedure was performed, - the name and title of the individual who performed the procedure, - all assessment data obtained during the procedure, - how the resident tolerated the procedure, - if the resident refused the procedure, the reason(s) why and the intervention taken, Page 1 of 4 555765 555765 06/25/2024 The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few - the blood sugar results. To follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results, and - the signature and title of the person recording the data. 1. Medical record review for Resident 2 was initiated on 6/24/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's MAR for June 2024 showed the following medications were scheduled to be administered on 6/6 and 6/14/24, at 0630 hours: - levothyroxine sodium (a medication to treat hypothyroidism, an underactive thyroid) 75 mcg by mouth for low thyroid hormone - regular insulin human injection (a medication used to lower the blood sugar) to inject subcutaneously before meals and at bedtime as per sliding scale as follows: - BS less than 70 mg/dL, to follow the facility's protocol and notify the MD. - BS 0 – 150 mg/dL, give 0 (zero) units. - BS 151 – 200 mg/dL, give two units. - BS 201 – 250 mg/dL, give four units. - BS 251 – 300 mg/dL, give six units. - BS 301 – 350 mg/dL, give eight units. - BS 351 – 400 mg/dL, give 10 units. - BS greater than 400 mg/dL, give 12 units and notify MD. However, further review of Resident 2's MAR for June 2024 showed the spaces for the license nurse to document the blood sugar levels, levothyroxine administered, amount of the regular insulin administered, and licensed nurses' initials were blank on 6/6 and 6/14/24 at 0630 hours. On 6/24/24 at 1516 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON stated she expected the licensed nurses to document the administration of the medications in the MAR right after the medications were administered. The DON verified the above findings. On 6/25/24 at 1420 hours, the Administrator, DON, and DSD were informed and acknowledged the above findings. 2. Medical record review for Resident 3 was initiated on 6/24/24. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's MAR for June 2024 showed the following medication was scheduled to be 555765 Page 2 of 4 555765 06/25/2024 The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705

F 0842 administered on 6/6 and 6/14/24 at 0630 hours: Level of Harm - Minimal harm or potential for actual harm - regular human insulin injections, subcutaneously before meals and at bedtime as per sliding scale as follows: Residents Affected - Few - BS 150 – 200 mg/dL, give three units. - BS 201 – 250 mg/dL, give six units. - BS 251 – 300 mg/dL, give nine units. - BS 301 – 350 mg/dL, give 12 units. - BS 351 – 400 mg/dL, give 15 units. - BS greater than 400 mg/dL, to call the physician. However, further review of Resident 3's MAR for June 2024 showed the spaces to document the blood sugar levels, amount of the insulin administered, and license nurses' initials were blank on 6/6 and 6/14/24 at 0630 hours. On 6/24/24 at 1516 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON stated she expected the licensed nurses to document the administration of the medications in the MAR right after the medications were administered. The DON verified the above findings. On 6/25/24 at 1420 hours, the Administrator, DON, and DSD were informed and acknowledged the above findings. 3. Medical record review for Resident 8 was initiated on 6/24/24. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 8 had a diagnosis of Parkinsonism. Review of Resident 8's Order Summary Report showed the physician order to administer the following medications: - amantadine hcl (a medication used to treat Parkinson's disease) 100 mg capsule, one capsule by mouth in the morning for antiparkinson, ordered on 2/28/24; - entacapone (a medication used to treat Parkinson's disease) 200 mg tablet, half a tablet by mouth every four hours for parkinsons, ordered on 3/5/24; and - carbidopa-levodopa (a medication used to treat Parkinson's disease) 25-100 mg table, 1.5 tablets by mouth every four hours for parkinsons, ordered on 3/5/24. Review of Resident 8's MAR for June 2024 showed to administer the following medications on 6/14/24, as scheduled: - entacapone tablet 200 mg, half a tablet by mouth and carbidopa-levodopa oral tablet 25-100 mg, to give 1.5 tablets by mouth at 0100 and 0500 hours; and 555765 Page 3 of 4 555765 06/25/2024 The Hills Post Acute 1800 Old Tustin Avenue Santa Ana, CA 92705

F 0842 - amantadine hcl oral capsule 100 mg at 0630 hours. Level of Harm - Minimal harm or potential for actual harm Review of Resident 8's MAR for June 2024 showed to administerthe following medications on 6/16/24, as scheduled: Residents Affected - Few - entacapone tablet 200 mg, half a tablet by mouth and carbidopa-levodopa oral tablet 25-100 mg, to give 1.5 tablets by mouth at 0500 hours; and - amantadine hcl oral capsule 100 mg at 0630 hours. However, further review of Resident 8's MAR for June 2024 showed the spaces for the licensed nurses' initials for medication administration were blank for the above scheduled medications on 6/14 and 6/16/24. On 6/24/24 at 1516 hours, an interview was conducted with the DON. The DON stated she expected the licensed nurses to document the administration of the medications in the MAR right after the medications were administered. On 6/25/24 at 1129 hours, an interview and concurrent medical record review for Resident 8 was conducted with the DON. The DON verified the above findings. On 6/25/24 at 1420 hours, the Administrator, DON, and DSD were informed and acknowledged the above findings. 555765 Page 4 of 4