Health inspection·February 13, 2026

Combined F759 S/S: K and F760 S/S: J §483.45(f) Medication Errors. The facility must ensure that its— §483.45(f)(1) Medication error rates are not 5 percent or greater; and §483.45(f)(2) Residents are free of any significant medication errors. California Code of Regulations, Title 22, Section 72301. Required Services. (f) The facility shall ensure that all orders written by a person lawfully authorized to prescribe shall be carried out unless contraindicated. California Code of Regulations, Title 22, Section 72311 Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (C) Reviewing, evaluating and updating of the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. (3) Notifying the attending licensed healthcare practitioner acting within the scope of his or her professional licensure promptly of: (B) Any sudden and/or marked adverse change in signs, symptoms or behavior exhibited by a patient. California Code of Regulations, Title 22, Section 72313 Nursing Service - Administration of Medications and Treatments (a) Medications and treatments shall be administered as follows: (2) Medications and treatments shall be administered as prescribed. California Code of Regulations, Title 22, Section 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 12/29/2025, the California Department of Public Health (CDPH) made an unannounced visit to the facility to conduct its annual health recertification survey. During the survey, CDPH identified on 12/30/2025 significant medication errors (the observed or identified preparation or administration of medications which are not in accordance with the prescriber’s order, manufacturer’s specifications, and accepted professional standards) affecting one resident (Resident 1) and an overall medication error rate of 24.14 percent (%) affecting two residents (Resident 1 and 69). The facility failed to ensure Resident 1 was free from significant medication errors and its medication error rate was below five (5) % for Resident 1 and Resident 69 during the Medication Administration Facility Task conducted on 12/30/2025. The facility had seven (7) medication errors out of 29 observed opportunities on 12/30/2025 during the 9 a.m. routine medication pass (a structured process of administering medications to ensure residents receive medications safely, accurately, and timely), resulting in an overall medication error rate of 24.14%. The facility failed to: 1. Obtain a physician’s order to crush Resident 1’s medications for administration via gastrostomy tube (g-tube, also known as an enteral tube – a soft tube inserted through the abdominal wall directly into the stomach, providing a way to deliver nutrition, fluids and medicine for individuals with swallowing difficulties).   2. Ensure Licensed Vocational Nurse 1 (LVN 1) flushed the g-tube with at least 15 milliliters (ml - a unit of measure for volume) of purified water between the administration of each of the following medications, as ordered by Resident 1’s physician: a. Acetaminophen (a medication used as a pain reliever and fever [abnormally high body temperature] reducer) b. Methocarbamol (a medication used to treat muscle spasms [sudden, involuntary, and often painful tightening or contraction of one or more muscles] and stiffness caused by muscle or bone conditions and injuries) c. Multiple Vitamins-Minerals tablet (a dietary supplement containing essential nutrients the body needs to work properly and stay healthy) d. Potassium Chloride 10% solution (an electrolyte [essential minerals that help balance the level of fluid in the body] supplement used to treat or prevent low levels of potassium [an essential mineral and electrolyte vital for nerve signals, muscle contractions {including the heart}, fluid balance, and blood pressure {BP} regulation] in the blood) e. Phenobarbital (medication that slows down the brain and central nervous system [CNS - made up of the brain and spinal cord, serves as a processing center that manages everything your body does], primarily used to control seizures [also known as epilepsy, a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking {movement}, blank stares, and loss of consciousness {a temporary state where a person becomes unaware of themselves and their surroundings}]) f. Miralax (also known as polyethylene glycol 3350, a medication used to treat occasional constipation [problem with passing stool]) 3. Ensure LVN 1 administered at least eight ounces (oz. – unit for measuring weight or liquid volume) of water with Resident 1’s Potassium Chloride solution as ordered by the physician. 4. Ensure Resident 1 had a care plan addressing g-tube medication administration. 5. Ensure the Director of Staff Development (DSD) observed LVN 1 administering medications via g-tube to ensure LVN 1 followed the standards of practice for g-tube medication administration. 6. Ensure Licensed Vocational Nurse 2 (LVN 2) administered a medication in accordance with the physician’s prescribed orders when LVN 2 failed to measure Resident 69’s heart rate (HR) prior to administering Amlodipine (a medication used to treat high BP) on 12/30/2025 during the 9 a.m. routine medication pass. As a result, Resident 1’s g-tube had the potential to become clogged due to medication buildup or drug incompatibility (refers to the undesirable reaction between two or more medicines, or a drug and a solution, causing changes in appearance, stability, safety or effectiveness, when the solutions are combined in the same syringe, tubing, or bottle) which may alter drug effects, reduce medication effectiveness, or result in overdosing from residual medication placing Resident 1 at risk for poor medication absorption, gastrointestinal (GI- relating to the stomach and the intestines [long, tube-shaped organ in the abdomen]) complications, ineffective treatment, potential seizure activity, hospitalization, and even death and had the potential to result in delayed care and treatment and mismanagement of Resident’s 69’s hypertension (abnormally high blood pressure) placing Resident 69 at risk for signs and symptoms of cardiac complications, including dizziness (feeling unsteady and feeling like you might faint) leading to falls, shortness of breath, and chest pain. A review of Resident 1’s Admission Record (AR), indicated the facility admitted the resident on 12/2/2025, with diagnoses including epilepsy, hemiplegia (total paralysis [loss of ability to move] of the arm, leg, and trunk on the same side of the body) and hemiparesis (a medical condition that causes weakness on one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels [tubular structure carrying blood through the tissues and organs] that supply it). A review of Resident 1’s History and Physical (H&P – a comprehensive assessment of a resident’s medical condition), dated 12/5/2025, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1’s Minimum Data Set (MDS - a resident assessment tool), dated 12/8/2025, indicated the resident rarely to never demonstrated the ability to make self-understood and understand others and had severely impaired cognitive skills (a significant decline in thinking, memory, and reasoning that makes it impossible for a person to live independently or perform daily tasks). The MDS further indicated the resident required a feeding tube and was prescribed a high-risk anticonvulsant medication (a type of drug that is used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain). A review of Resident 1’s Order Summary Report (OSR – a document that provides a consolidated, current list of all medications prescribed for a resident) for December 2025, indicated the following Physician Orders: a. Dated 12/11/2025. Acetaminophen oral tablet 325 milligram (mg – a unit of measure for weight). Give two tablets via g-tube three times a day for pain management not to exceed (NTE) three grams (gm- a unit of mass [weight]) of Acetaminophen from all sources within a 24-hour period. b. Dated 12/3/2025. Methocarbamol oral tablet 750 mg. Give two tablets via g-tube three times a day for muscle spasms. c. Dated 12/2/2025. Multiple Vitamins-Minerals tablet. Give one tablet via g-tube one time a day for supplement. d. Dated 12/3/2025. Potassium chloride 10% oral solution, 20 milliequivalent (meq - a unit of measurement) per 15 ml. Give 15 ml via g-tube one time a day for potassium supplement, give with at least 8 oz. of water. e. Dated 12/2/2025. Phenobarbital oral tablet 30 mg. Give one tablet via g-tube two times a day for seizure. f. Dated 12/2/2025. Polyethylene Glycol 200 Liquid (Polyethylene Glycol 200) [sic – entry appears erroneous]. (Polyethylene Glycol 200 was possibly entered in error, as Polyethylene Glycol 3350 {Miralax} was observed during Medication Administration Facility Task on 12/30/2025). Give 17 gm via g-tube one time a day every Mon, Tue, Thu, and Fri for bowel management. Mix with four to eight oz. of water (prior to administration) and give via g-tube; Hold if with loose bowel movement (BM). g. Dated 12/2/2025. Enteral feeding order: Flush the feeding tube every shift with at least 15 ml of purified water between each medication. Flush one final time with at least 15 ml purified water after all medications are administered. The OSR for December 2025 reviewed on 12/30/2025 did not indicate a physician order for medications to be crushed before administration via g-tube. A review of Resident 1’s Care Plan (CP) Report titled, “Impaired neurological function related to complex central nervous system disorders and neuromuscular (relating to nerves and muscles) impairment…,” initiated on 12/30/2025, indicated an intervention to administer phenobarbital and methocarbamol as ordered and to monitor the resident’s (Resident 1) therapeutic response and observe for adverse effects (an undesired effect of a drug or other type of treatment). During an observation on 12/30/2025 at 8:31 a.m., with LVN 1, during the Medication Administration Facility Task, observed LVN 1 in front of Resident 1’s room preparing for the morning (9 a.m.) medication pass. LVN 1 removed the following medications from the medication cart: 1. Acetaminophen 325 mg oral tablets. 2. Methocarbamol 750 mg oral tablets. 3. Multiple Vitamins-Minerals one tablet. 4. Potassium Chloride oral solution 20 meq/15 ml (10%). 5. Phenobarbital 30 mg oral tablet. 6. Miralax 17 gm packet. LVN 1 crushed two 325 mg Acetaminophen tablets and placed them into a medication cup. LVN 1 crushed two 750 mg Methocarbamol tablets and placed them into a medication cup. LVN 1 crushed one Multiple Vitamins-Minerals tablet and placed it into a medication cup. LVN 1 poured 15 ml of Potassium Chloride oral solution 20 meq/15 ml into a medication cup. LVN 1 crushed one 30 mg Phenobarbital tablet and placed it into a medication cup. LVN 1 mixed the Miralax packet with approximately four to eight oz. of water in a drinking cup. LVN 1 donned (put on) a gown, mask, and gloves and placed the prepared medications on the bedside (place next to a resident’s bed) table. LVN 2 identified Resident 1 using the armband and Point Click Care (PCC- an electronic healthcare record system). LVN 1 checked the g-tube placement by checking for residuals and listening for gurgling sounds using a stethoscope (a medical tool that helps healthcare providers listen to internal body sounds, like heartbeats, breathing, and gut noises, by amplifying them through earpieces connected to a chest piece, allowing for diagnosis of heart, lung, and intestinal issues) on the abdomen while flushing air into the g-tube. LVN 1 confirmed Resident 1’s g-tube placement. LVN 1 flushed the g-tube with 15 ml of water. LVN 1 then took the crushed acetaminophen tablets, poured 15 ml of water in the cup, mixed the medication using the piston syringe (a medical device with a hollow barrel and a movable plunger used to inject or withdraw fluids from the body, featuring a nozzle for attaching needles or tubing, offering precise control for applications like wound irrigation, medication delivery, or lab use) tip, aspirated (pulling back on the plunger on the piston syringe to draw up medication) the medication into the syringe and administered the medication via Resident 1’s g-tube. LVN 1 repeated this process for the crushed Methocarbamol tablets and the crushed Multiple Vitamins-Minerals tablet, administering each medication via the g-tube without flushing the g-tube with at least 15 ml of purified water between each medication. LVN 1 took the crushed Methocarbamol tablets, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1’s g-tube. LVN 1 took the crushed Multiple Vitamins-Minerals, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1’s g-tube. LVN 1 aspirated the 15 ml of Potassium Chloride oral solution from the unit dose cup (a single-use container designed to hold a pre-measured, individual dose of liquid medication) and administered the medication via piston syringe through the g-tube, LVN 1 then added 15 ml of water to the empty medication cup to wash off remaining medication, aspirated the water mixed with the remaining solution, and administered the medication via Resident 1’s g-tube. LVN 1 did not follow the physician’s order to administer the Potassium Chloride with at least 8 oz. of water. LVN 1 took the crushed Phenobarbital, poured 15 ml of water in the cup, mixed the medication using the piston syringe tip, aspirated the medication into the syringe, and administered the medication via Resident 1’s g-tube. LVN 1 took the Miralax solution and administered the medication via Resident 1’s g-tube. Following medication administration, LVN 1 flushed Resident 1’s g-tube with an additional 15 ml of water and re-connected the resident to the enteral feeding. LVN 1 removed her (LVN 1) gown and gloves, washed her hands, and documented the medication administration. During a concurrent interview and record review on 12/30/2025 at 9:15 a.m., with LVN 1, in front of Resident 1’s room, Resident 1’s OSR for December 2025 and Medication Administration Record (MAR- a document tracking every medication given to a resident, detailing the drug, dose, time, route) for 12/30/2025 were reviewed. LVN 1 stated she (LVN 1) had been working in the facility since July 2025 and could not recall being observed or evaluated for medication administration via g-tube. She (LVN 1) administers medication via g-tube, each medication should be prepared in a separate medication cup and should not be mixed with other medications. G-tube medications should be administered one at a time and that the tubing should be flushed with 15 to 30 ml of water, depending on the physician’s order. Prior to medication administration, she (LVN 1) checks g-tube placement by instilling air into the tubing and listening for gurgling sounds. I If a medication is in powdered or crushed form, she (LVN 1) reconstitutes (to add liquid to a dry or powdered medication to make a solution) the medication by adding 15 ml of water to dissolve the medication for g-tube administration. She (LVN1) was supposed to pour the medication one at a time slowly through the barrel of the piston syringe by gravity for medication administration via g-tube, however, with Resident 1 she (LVN 1) decided to push