Health inspection·February 27, 2024

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 the narcotic and hypnotic record (accountability record of controlled medications that are considered to have strong potential for abuse) was accurately documented for three out of eight sampled residents (Resident 5, Resident 6, and Resident 7). This deficient practice resulted in inaccurate reconciliation of the controlled medications (tramadol [a strong painkiller from a group of medicines called opiates, or narcotics], hydrocodone-acetaminophen [Norco (a combination opioid medication used to manage pain when non-opioid medications aren't working well enough)], and zolpidem tartrate [used to treat insomnia (trouble sleeping)]) and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use of unintended purposes) of controlled medication for Resident 5, 6, and 7. Findings: a. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 11/3/2023, with diagnoses including hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease), fibromyalgia (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues), and peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart). A review of Resident 5 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/12/2023, indicated Resident 5 had the ability to understand and was able to be understood. The MDS indicated Resident 5 required substantial to maximal assistance with showering, dressing lower body and required partial to moderate assistance with toileting hygiene. A review of the Physician's Orders for Resident 5, dated 11/7/2023, indicated hydrocodone-acetaminophen oral tablet 5-325 milligrams (mg- a unit of measurement) give 1 tablet by mouth every 8 hours as needed for mild to moderate pain. b. A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 9/21/2019 and was readmitted on [DATE], with diagnoses included encephalopathy (damage or disease that affects the brain), chronic obstructive pulmonary disease (COPD- a common lung disease causing restricted airflow and breathing problems), and peripheral vascular disease (the reduced circulation of blood to a body part other than the brain or heart). A review of Resident 6 ' s Minimum Data Set (MDS - a standardized assessment and care screening Page 1 of 3 555791 555791 02/27/2024 The Gardens Healthcare Center 17650 Devonshire Street Northridge, CA 91325

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tool), dated 1/30/2024, indicated Resident 6 had the ability to understand and was able to be understood. The MDS indicated Resident 6 was dependent on personal hygiene, required substantia to maximal assistance with toileting hygiene, upper and lower body dressing, and putting on and taking off footwear. A review of the Physician's Orders for Resident 6, dated 12/4/2023, indicated tramadol 50 mg 1 tablet by mouth every 6 hours as needed for moderate pain 4 to 6 out of 10. c. A review of Resident 7 ' s admission Record indicated the facility admitted the resident on 10/3/2023, with diagnoses included dislocation (a separation of two bones where they meet at a joint) of right shoulder joint, muscle weakness (general), and chronic pain syndrome (any pain lasting longer than three months). A review of Resident 7 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/5/2023, indicated Resident 7 had the ability to sometimes understand and was able to be understood sometimes. The MDS indicated Resident 7 was dependent on eating and personal hygiene and required substantial to maximum assistance with oral hygiene, and upper body dressing. A review of the Physician ' s Orders for Resident 7, dated 10/20/2023, indicated zolpidem tartrate 5 mg 1 tablet by mouth every 24 hours as needed for insomnia inability to sleep. During a record review of the Antibiotic or Controlled Drug Record on 2/27/2024 at 10:51 a.m. for: - Resident 5 ' s hydrocodone-acetaminophen 5-325 mg indicated the disposition of remaining doses was missing disposition date and quantity of doses disposed. - Resident 6 ' s tramadol 50 mg indicated number of tablets left were 25 and disposition of remaining doses indicated quantity of doses disposed 30, indicated doses discharged with patient quantity 25. - Resident 7 ' s zolpidem tartrate 5 mg indicated number of tablets left were 11 and disposition of remaining doses was missing quantity of doses disposed. During a concurrent interview and record review on 2/27/2024 at 2 p.m. on the Antibiotic or Controlled Drug Record for Resident 5 ' s Norco 5-325 mg, the Assistant Director of Nursing (ADON) stated it should have included the quantity of doses left and should have been dated. The ADON stated that for Resident 6 ' s tramadol 50 mg it indicates there were 25 doses left but disposed were 30, then it also indicated 25 doses were discharged with the resident. The ADON stated that for Resident 7 ' s zolpidem tartrate 5 mg it indicates 11 doses left and there is no indication of how many medications were disposed of. The ADON stated all narcotic counts are reviewed with the pharmacist and the DON and should be accurately documented to ensure accuracy. During a concurrent interview and record review on 2/27/2024 at 3:10 p.m., the Director of Nursing (DON) stated that for Resident 6 the quantity indicates 25 doses left then indicates 30 doses were disposed of, but discharge to resident indicated 25. The DON stated this was by mistake because 30 was the original total dosages but pharmacist wrote 25 under the family spot. The DON stated for Resident 5 there is no date or quantity and it needs to have the quantity to verify the count is accurate and the date needs to be indicated to know the date of disposition. The DON stated that for Resident 7 there is no quantity and it appears to be 12 doses but 1 dose was given, should have 11 disposed 555791 Page 2 of 3 555791 02/27/2024 The Gardens Healthcare Center 17650 Devonshire Street Northridge, CA 91325

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some under the quantity. The DON stated there is a risk to make it difficult to monitor the narcotics and what is disposed of because it can lead to a discrepancy. A review of the facility's policy and procedure titled, Disposal of Medications and Medication-related supplies, last revised on 10/2017, indicated discontinued medications and medications left in the facility after a resident ' s discharge, which do not qualify for return to the pharmacy for credit, are destroyed. d. The nurse(s) and/or pharmacist witnessing the destruction ensure that the following information is entered on the medication disposition form. 1. Date of destruction 2. Resident ' s name 3. Name and strength of medication 4. Prescription number 5. Amount of medication destroyed 6. Signatures of witness 555791 Page 3 of 3