Health inspection·January 29, 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 interview and record review, the facility failed to provide pharmaceutical services to meet the needs of one of four residents (Resident 1) when the facility did not provide a prescribed dose of Insulin Glargine (a medication to control blood sugar) and three prescribed doses of Potassium (a supplement for the prevention of kidney stones - a small, hard deposit that forms in the kidneys and is often painful when passed) for one of three sampled residents (Resident 1). These failures had the potential for Resident 1 to experience adverse health outcomes. Findings: During a review of Resident 1's Physician Orders , dated 1/1/25-1/31/25, the Physician Orders indicated Resident 1 was admitted to the facility on [DATE], had diagnoses including diabetes mellitus (a condition affecting blood sugar levels). The Physician Orders indicated the following medication orders: a) 1/24/25 (Insulin Glargine) BASAGLAR KWIKPEN.50 units subcutaneous TWICE DAILY AT 0900 & 2200 b) 5/2/24 (Potassium Citrate) POTASSIUM CITRATE 10 MEQ TABLET, EXTENDED RELEASE 1 TAB ORAL 3 TIMES DAILY for prophylactic [preventive] measures .for MANAGEMENT OF RENAL [kidney] STONES. During an interview on 1/29/25 at 1:50 p.m. with Resident 1, Resident 1 stated she had missed her morning dose of Insulin Glargine on 1/29/25, had not been given two doses of Potassium on 1/27/25, and also missed Potassium doses in other days in January (2025). Resident 1 stated she missed those doses because the facility ran out of the medications. During a review of Resident 1's Medication Administration Record (MAR-where licensed nurses document medications given to residents), dated 1/1/25-1/31/25, the MAR indicated a blank space in the administration field for the Insulin Glargine dose scheduled for 1/29/25 at 9 a.m. The MAR also indicated H [held] for the Potassium doses scheduled for 1/27/25 at 9 a.m. and 12 p.m. and 1/13/25 at 9 a.m. During a review of Resident 1's Order History (where licensed nurses document medication administration variances), for the Potassium order for the period 1/1/25-1/31/25, the Order History indicated the Potassium doses scheduled for 1/27/25 at 9 a.m. and 12 p.m. and 1/13/25 at 9 a.m. were not given because Medication not available. During an interview on 1/29/25, at 2:10 p.m., with Licensed Nurse A (LN) A, LN A stated she was Resident 1's nurse and had administered her medications on 1/29/25. LN A stated Resident 1 was not Page 1 of 2 555877 555877 01/29/2025 Ridgecrest Regional Transitional Care and Rehabili 1081 North China Lake Boulevard Ridgecrest, CA 93555

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few given her morning dose of Insulin Glargine on 1/29/25 because the facility ran out of the medication and the pharmacy did not deliver a new Insulin Glargine pen on time for the 9 a.m. dose. During an interview on 1/29/25, at 2:40 p.m., with Director of Nursing (DON), DON stated Resident 1 had missed the morning dose of Insulin Glargine on 1/29/25 and the Potassium doses on 1/27/25 at 9 a.m. and 12 p.m. and 1/13/25 at 9 a.m. During an interview on 2/27/25, at 3:02 p.m. with DON, DON stated, The responsibility to ensure residents' medications are available are the floor nurses [LVN's] who pass meds [medications]. If they [LVNs] notice a resident's medication supply is running low, they [LVNs] are responsible for reordering that medication before it [medications] runs out. During a review of facility policy and procedure (P&P) titled, Administering Medication, Revised April 2019, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribed orders, including any required time frame. 555877 Page 2 of 2