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 follow their policy and procedure for unusable
drugs when morphine sulfate (a prescription narcotic pain medication) with no active Physician's Order was
not removed from the medication cart.
This failure resulted in the unauthorized administration of morphine sulfate without a physician's order to
Resident 1.
Findings:
During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was admitted on [DATE]
with diagnoses including osteoarthritis (chronic joint disease that can cause pain) of hip.
During a review of Resident 1's Morphine Sulfate Inventory Log, current as of [DATE], the log indicated
Licensed Vocational Nurse (LVN) signed out dose #13 on [DATE] at 00:00 a.m.
During a review of Resident 1's Physician's Orders, dated [DATE], the orders indicated, Morphine sulfate 15
milligram tablet to be taken by mouth twice a day as needed for moderate to severe pain. The order
indicated an end date of [DATE]. Facility unable to provide documentation of an active order for morphine
sulfate on [DATE].
During an interview on [DATE] at 9:06 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that if a
medication order for a narcotic expired the medication nurse would notify the Charge Nurse (CN). LVN 2
stated the CN would get a new order or would take the narcotics to the pharmacy to be destroyed.
During an interview on [DATE] at 10:08 a.m. with Pharmacy Manager (PM), PM stated that medications
with no active orders should not stay in the active medication stock.
During a review of the facility's policy and procedure (P&P) titled, Expired-Unusable Meds, dated [DATE],
the P&P indicated, Unusable drugs include those that are . Partially used by a patient and has been
discontinued by the prescriber . Unusable drugs shall not be distributed or administered. Pharmacy,
nursing, and other personnel who discover unusable drugs shall properly dispose of the drugs as listed
below or keep the drugs segregated from usable stock in a separate, locked storage area until properly
disposed of. In the case of controlled drugs, a zip lock bag labeled DO NOT USE may be utilized to
segregate the unusable stock (along with its controlled drug record) from the active stock within the
controlled drug storage compartment.
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 2
Event ID:
555917
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
555917
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Veterans Home of California - West Los Angeles
11500 Nimitz Avenue
Los Angeles, CA 90049
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)
F 0760
Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure Resident 1 was free of any significant medication
error when Resident 1 was administered morphine sulfate (a prescription pain medication) without a
physician's order.
Residents Affected - Few
This failure resulted in the unauthorized administration of morphine sulfate.
Findings:
During a review of Resident 1's Face Sheet, the Face Sheet indicated, Resident 1 was admitted on [DATE]
with diagnoses including osteoarthritis (chronic joint disease that can cause pain) of hip.
During a review of Resident 1's Morphine Sulfate Inventory Log, current as of 10/31/24, the log indicated
Licensed Vocational Nurse (LVN) 1signed out dose #13 on 10/18/24 at 00:00 a.m.
During a review of Resident 1's Physician's Orders, dated 7/15/24, the orders indicated, Morphine sulfate
15 milligram tablet to be taken by mouth twice a day as needed for moderate to severe pain. The order
indicated an end date of 10/12/24. The facility was unable to provide documentation of an active physicians
order for morphine sulfate on 10/18/24.
During an observation and interview on 10/31/24 at 8:30 a.m. by room A311 with Registered Nurse (RN),
RN was observed checking the Physician's Orders for the medications she was preparing to administer. RN
stated that when preparing medications, the physician's order, medication's expiration date, and the
medication's label must be checked.
During an interview on 10/31/24 at 9:21 a.m. with Supervisor Registered Nurse (SRN), SRN stated the
licensed nurse administering the medication was expected to check the Physician's Orders before
administering the medication. The SRN stated the LVN 1 administered the morphine sulfate without a
physician's order.
During an interview on 10/31/24 at 10:26 a.m. with LVN 1, LVN 1 stated she remembered administering the
morphine sulfate because the patient was complaining of pain, but she did not see the MD order.
During a review of the facility's policy and procedure (P&P) titled, Medication, Administration Standards,
dated 6/21/24, the P&P indicated, Medications and treatments are administered only on the order of a
physician or other person legally authorized to give such orders. The P&P also indicated, The licensed
nurse in responsible to ensure the Six rights of medication administration are followed at all times: 1. Right
Resident, 2. Right Medication, 3. Right Dose, 4. Right Route, 5. Right Time, 6. Right Documentation .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
555917
If continuation sheet
Page 2 of 2
