Health inspection·May 13, 2025

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 provide clear indications (a valid reason to use a certain medication) for two of three sampled residents ' (Resident 1 and Resident 2) controlled pain medications (medications with high abuse potential). As a result of this deficient practice, Resident 1 and Resident 2 were at risk of receiving unnecessary controlled pain medications which may lead to misuse. Findings: 1. Resident 1 was admitted to the facility on [DATE], with the diagnosis which included cellulitis (a skin infection) of the right leg per facility's admission Record. A review of Resident 1 ' s physician ' s orders dated 3/21/25, indicated: · Oxycodone HCL Oral Tablet (a type of strong pain reliever that could be habit-forming if not used exactly as prescribed) 5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for moderate pain level 4-6 (pain scale that utilize numbers used to evaluate a person ' s perceived pain level). · Oxycodone HCL Oral Tablet 5 MG (Oxycodone HCL). Give 2 tablets by mouth every 6 hours as needed for severe pain level 7-10. These orders included the parameter for use, but did not include the indication of the controlled medications. A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/13/25 at 9:59 A.M., indicated oxycodone was given for .lower back pain A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/11/25 at 6:39 P.M., indicated oxycodone was given for .buttock pain A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/10/25 at 8:46 P.M., indicated oxycodone was given for .generalized pain A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/9/25 at 3:46 P.M., indicated oxycodone was given for .Resident c/o [complained of] pain. Page 1 of 4 555873 555873 05/13/2025 South Bay Post Acute Care 553 F Street Chula Vista, CA 91910

F 0755 Level of Harm - Minimal harm or potential for actual harm A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/7/25 at 9:25 P.M., indicated oxycodone was given. There was no documented location of pain. A review of Resident 1 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/6/25 at 7:16 P.M., indicated oxycodone was given. There was no documented location of pain. Residents Affected - Few 2. Resident 2 was admitted to the facility on [DATE], with diagnosis which included right femur (thigh bone) fracture per facility's admission Record. A review of Resident 2 ' s physician ' s orders dated 5/4/25, indicated: · Hydrocodone-Acetaminophen Oral Tablet (a type of strong pain reliever that could be habit-forming if not used exactly as prescribed) 5-325 MG. Give 1 tablet by mouth every 4 hours as needed for moderate pain level 4-6. · Hydrocodone-Acetaminophen Oral Tablet 10-325 MG. Give 1 tablet by mouth every 4 hours as needed for severe pain level 7-10. These orders included the parameter for use, but did not include the indication of the controlled medications. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/13/25 at 4:55 A.M., indicated Hydrocodone-Acetaminophen was given for .pain in her leg. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/12/25 at 9:54 P.M., indicated Hydrocodone-Acetaminophen was given for Pt [patient] reported 7/10 pain numeric scale There was no documented location of pain. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/12/25 at 7:09 A.M., indicated Hydrocodone-Acetaminophen was given for Resident wants her pain pill for her leg. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/10/25 at 7:22 P.M., indicated Hydrocodone-Acetaminophen was given. There was no documented location of pain. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/9/25 at 8:32 A.M., indicated Hydrocodone-Acetaminophen was given. There was no documented location of pain. A review of Resident 2 ' s Progress notes, titled eMAR-Medication Administration Note, dated 5/8/25 4:35 A.M., indicated Hydrocodone-Acetaminophen was given for .LE (lower extremity) pain On 5/13/25 at 12:08 P.M., an interview and record review was conducted with Licensed Nurse (LN) 1. LN 1 reviewed Resident 1 and Resident 2 ' s physician ' s orders and stated that the orders needed to be updated because they were missing the indication for use. LN 1 stated the physician ' s orders for controlled pain medications, should be more specific to prevent medication misuse. On 5/13/25 at 12:23 P.M., an interview and record review was conducted with the Assistant Director 555873 Page 2 of 4 555873 05/13/2025 South Bay Post Acute Care 553 F Street Chula Vista, CA 91910

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of Nursing (ADON). The ADON stated a complete medication order should include a clear indication of use. The ADON stated clear indications were important to prevent unnecessary use of controlled medications. The ADON reviewed Resident 1 ' s eMAR-Medication Administration Notes and stated Resident 1 ' s oxycodone was administered for different locations of pain. The ADON stated he was unsure what condition Resident 1 ' s oxycodone was intended to treat. The ADON stated Resident 1 and Resident 2 ' s controlled medication orders needed to be clarified with the physician to include a clear indication for their use. On 5/13/25 at 1:56 P.M., an interview was conducted with the Director of Nursing (DON). The DON stated controlled pain medication orders should be written with clear and specific indications of use. The DON stated this was important because a change of condition could be missed when a resident has a new pain. The DON stated the new pain may be different from what the physician had originally intended the medication to treat. On 5/13/25 at 4:29 P.M., an interview and record review was conducted with the DON. The DON stated the facility did not have a Policy and Procedure for unnecessary medication, but the facility followed Physician Orders Policy and Procedure. A review of the facility ' s undated policy titled Physician Orders, indicated, .7. Orders for medications must include: . E. Reason or problem for which given. 555873 Page 3 of 4 555873 05/13/2025 South Bay Post Acute Care 553 F Street Chula Vista, CA 91910

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 observation, interview, and record review, the facility failed to accurately document a pain assessment result and controlled pain medication (medications with high abuse potential) administration in the Medication Administration Record (MAR) for one of three sampled residents (Resident 1). As a result of this deficient practice, Resident 1 ' s MAR did not accurately reflect the care and treatment provided to the resident. Findings: Resident 1 was admitted to the facility on [DATE], with diagnosis which included cellulitis (a skin infection) of the right leg per facility's admission Record. A review of Resident 1 ' s physician ' s orders dated 3/21/25, indicated: · Oxycodone HCL Oral Tablet (a type of strong pain reliever that could be habit-forming if not used exactly as prescribed) 5 MG (milligrams). Give 1 tablet by mouth every 6 hours as needed for moderate pain level 4-6 (pain scale that utilizes numbers used to evaluate a person ' s perceived pain level). · Oxycodone HCL Oral Tablet 5 MG (Oxycodone HCL). Give 2 tablets by mouth every 6 hours as needed for severe pain level 7-10. A review of Resident 1 ' s Controlled Drug Record (CDR) dated 5/12/25 at 8:12 P.M., indicated two tablets of Oxycodone HCL Oral Tablet 5 MG were removed from the locked medication cart by Licensed Nurse (LN) 3. A review of Resident 1 ' s MAR dated 5/12/25 at 8:12 P.M., indicated one tablet of Oxycodone HCL Oral Tablet 5 MG was administered to Resident 1 by LN 3. The MAR also indicated Resident 1 had a pain level rated 4/10. On 5/13/25 at 3:23 P.M., an interview and record review was conducted with LN 3. LN 3 reviewed Resident 1 ' s MAR and CDR dated 5/12/25 at 8:12 P.M. LN 3 stated he administered two tablets of oxycodone for a pain level of 7 to Resident 1. LN 3 stated the documentation on the MAR was incorrect. On 5/13/25 at 4:25 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated Resident 1 ' s pain assessment and oxycodone administration should have been documented accurately. A review of the facility ' s undated policy titled Policy Procedure Documentation and Charting, indicated, It is the policy of this facility to provide an accurate account of documentation of the resident ' s clinical care and/or status in the clinical record 555873 Page 4 of 4