Health inspection·November 2, 2023

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a resident was assessed to determine if self-administration of medication was clinically appropriate for 1 (Resident #48) of 6 sampled residents reviewed for medication administration. Specifically, Resident #48 was found with two white pills in a small cup at bedside with no staff present without an assessment of the resident's ability to safely self-administer the medication. Residents Affected - Few Findings included: A review of a facility policy titled, Medications, Self-Administration, reviewed on 01/31/2022, revealed, It is the policy of this facility that an individual resident may self-administer specific medications if the IDT [interdisciplinary team] has determined that this practice is safe, and physician orders are obtained for self-administration of the specific medication(s). The policy specified, 2. If a resident voices desire to self-administer medications, the IDT is to assess the resident's cognitive, physical and visual ability to carry out this responsibility. 3. A licensed nurse is to complete the Self-Administration of Medication Assessment (UDA) [user defined assessment]. The resident is to be asked to read and understand the directions on the pharmacy label, and to administer his/her medications in the presence of a licensed nurse to demonstrate the ability to take the medication according to the safe practice and facility policy. 4. The self-administration assessment and any other information is to be reviewed by the resident's physician and IDT for final determination of the resident's ability to self-administer medications. The policy indicated, The resident may not begin self-administration of medications prior to the approval of the physician and IDT. A review of Resident #48's admission Record revealed the facility admitted the resident on 09/29/2023 with diagnoses that included end stage renal disease and dependence on renal dialysis. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/04/2023, revealed Resident #48 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Per the MDS, Resident #48 received dialysis while residing in the facility. A review of Resident #48's care plan revised on 10/01/2023, t indicated the resident needed hemodialysis related to renal failure. A review of Resident #48's Order Summary Report, that listed active orders as of 10/30/2023, revealed an order dated 09/29/2023, for sevelamer carbonate (a medication used to lower high blood phosphorus levels in patients on dialysis) 800 milligrams (mg), two tablets by mouth before meals for hypocalcemia. There was no physician's order for Resident #48 to self-administer their medications. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 11 Event ID: 555901 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555901 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/02/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Anberry Transitional Care 1000 West Yosemite Avenue Merced, CA 95341 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)