Health inspection·August 13, 2025

REGULATORY VIOLATIONS: Code of Federal Regulations, Title 42, §483.45(f) Medication Errors. The facility must ensure that its — (2) Residents are free of any significant medication errors. California Code of Regulations, Title 22, § 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. California Code of Regulations, Title 22, § 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, § 72311 Nursing Service – General (a) Nursing service shall include, but not be limited to, the following: (2) Implementing of each patient’s care plan according to the methods indicated. Each patient’s care shall be based on this plan. On 6/24/2025, at 8 AM, the California Department of Public Health (CDPH) conducted an unannounced visit to the facility for the facility’s annual recertification survey. As a result of the investigation, the CDPH determined the facility failed to follow its Policies and Procedures (P&P) titled, "Physician Orders," "Pain Management," "Medication - Administration," and the manufacture specifications on the medication card (also known as bubble/blister packs, packaging that organizes and dispenses medications in individual doses) to prevent significant medication errors (medication errors that causes the resident discomfort or jeopardizes the resident health and safety) for Resident 51 by failing to ensure: A. Licensed Vocational Nurse (LVN) 2 followed the medication card for Potassium Chloride indicating “Do not crush,” and followed Resident 51's physician/Medical Doctor (MD) 1's orders indicating to administer medications with food/water. B. Pain medication was administered before Resident 51’s wound care treatment and Ascorbic Acid and Zinc were administered from 6/4/2025 to 6/24/2025 (omitted for 21 days). As a result of these failures, Residents 51 did not receive medications in accordance with the physicians' orders, the facility's P&Ps, or the specifications on the medication card. These failures placed Resident 51 at risk for significant medical complications including pain and delayed wound healing. A review of Resident 51's Admission Record (AR), indicated Resident 51, a 91-year-old-female, was readmitted to the facility on 3/8/2025 with diagnoses that included, stage 4 pressure ulcer (PU) of the sacral region, hypokalemia, protein-calorie malnutrition, and gastro-esophageal reflux disease (GERD). A review of Resident 51's untitled care plan (CP), dated 4/21/2025, indicated Resident 51 had a stage 4 PU on the sacral-coccyx area that extended to the left and right buttocks. The CP's interventions indicated "Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort." A review of Resident 51's Order Summary Report (OSR), dated active as of 6/24/2025, indicated Resident 51 had active medication orders for the following morning medications: 1. Acetaminophen tablet 325 mg, give two tablets by mouth every "day shift" for pain management. The order indicated to give 30 minutes before treatment, order date 3/31/2025. 2. Xarelto oral tablet 15 mg, give one tablet by mouth one time a day for atrial fibrillation (a-fib), dated 3/13/2025. 3. Glimepiride oral tablet 1 mg, give one tablet by mouth one time a day for diabetes mellitus (DM), order date 3/13/2025. 4. Potassium Chloride ER oral tablet 10 milliequivalents (meq), give one tablet by mouth one time a day for supplement. The order indicated to administer with or after meals with 4-8 ounces (oz) of water, dated 4/7/2025. 5. Digoxin oral tablet 125 mcg, give one tablet by mouth one time a day for heart failure. Hold if the heart rate (HR) is less than 60 beats per minute, dated 3/13/2025. 6. Docusate Sodium oral capsule 250 mg, give one capsule by mouth one time a day for bowel management. Hold for loose stool, dated 5/7/2025. 7. Furosemide oral tablet 40 mg, give one tablet by mouth one time a day for congestive heart failure (CHF,). Hold for systolic blood pressure less than 110 millimeters of mercury (mmHg), dated 5/25/2025. 8. Multivitamins with Minerals oral tablet, give one tablet by mouth one time a day for wound healing support, dated 3/18/2025. 9. Polyethylene Glycol 3350 oral powder 17 grams (g)/scoop, give one scoop by mouth one time a day for bowel management, give with 8 oz of water, dated 4/7/2025. 10. Spironolactone oral tablet 50 mg, give one tablet by mouth one time a day for CHF, dated 3/13/2025. 11. Ascorbic Acid oral tablet 500 mg, give one tablet by mouth one time a day for supplement, dated 6/4/2025. 12. Zinc Sulfate oral tablet 220 mg, give one tablet by mouth one time a day for supplement for one month, dated 6/4/2025. During a concurrent medication pass observation and interview on 6/24/2025 at 9:55 AM, with LVN 2, in Station 3, Med Cart 3, LVN 2 prepared the following medications for Resident 51: 1. Two tablets of Acetaminophen 325 mg. 2. One tablet of Xarelto 15 mg. 3. One tablet of Glimepiride 1 mg. 4. One tablet of Potassium Chloride ER 10 meq. 5. One tablet of Digoxin 125 mcg. 6. One capsule of Docusate Sodium 250 mg. 7. One tablet of Furosemide 40 mg. 8. One tablet of Multivitamins with Minerals. 9. One scoop of Polyethylene Glycol Oral Powder 17 g. 10. One tablet of Spironolactone 50 mg. 11. Insulin Glargine 15 units (u) subcutaneously (SQ). LVN 2 stated the medications listed above were the only medications to administer to Resident 51 "this morning." During a concurrent medication pass observation and interview with LVN 2 on 6/24/2025, at 11:04 AM, LVN 2 was observed crushing the medications individually and placing each medication into separate medicine cups with half a teaspoon of apple sauce. A review of Resident 51's Potassium Chloride ER bubble pack and interview with the Assistant Director of Nursing (ADON) on 6/24/2025, at 11:06 AM, the Potassium Chloride ER medication card indicated "Do not crush." The ADON stated Potassium Chloride ER tablets should not be crushed, as indicated on the medication card. The ADON stated LVN 2 should have double checked the medication card to make sure Potassium Chloride ER was crushable. The ADON stated LNV 2 needed to contact the physician to get an order for a liquid form. The ADON stated crushing Potassium Chloride ER could cause the medication to be released immediately and lead to high levels of potassium in Resident 51’s blood which could cause an irregular heart rhythm. During a medication pass observation on 6/24/2025, at 11:12 AM, LVN 2 was administering medications to Resident 51. The medications were mixed with half a teaspoon of apple sauce and taken with water. Resident 51 only accepted two oral medications: one tablet of Acetaminophen 325 mg and one tablet of Furosemide 40 mg. Resident 51 refused the remaining oral medications. During an interview with Resident 51 on 6/24/2025 at 11:27 AM, Resident 51 stated Resident 51 did not want to take the rest of the medications because taking so many pills on an empty stomach hurt Resident 51's stomach. Resident 51 stated Resident 51 had not been offered food with the morning medications. Resident 51 stated Resident 51 received wound care treatments every morning and the nurses were supposed to offer pain medication before treatment. Resident 51 stated, "this morning” (6/24/2025), Resident 51 did not receive pain medication prior to the treatment, and the wound care treatment was "very painful (unable to rate the pain). During an interview with Treatment Nurse (TN) 2 on 6/25/2025, at 11:05 AM, TN 2 stated the wound care treatment for Resident 51 was completed between 5 AM and 6 AM on 6/24/2025. TN 2 stated TN 2 was unaware if Resident 51 received pain medication prior to the wound care treatment. TN 2 stated TN 2 was supposed to coordinate with the charge nurse to ensure Resident 51 received the scheduled pain medication prior to the treatments to prevent Resident 51 from having pain. A review of Resident 51’s Medication Administration Record (MAR), dated June 2025, indicated no pain medication was administered to Resident 51 on 6/24/2025. During a concurrent record review and interview with LVN 2 on 6/25/2025, at 12:07 PM, Resident 51's OSR for the month of June 2025 was reviewed, and LVN 2 stated the orders for Ascorbic Acid and Zinc Sulfate were placed on 6/4/2025, but were not in Resident 51's MAR. LVN 2 stated Resident 51 did not receive these medications (Ascorbic Acid and Zinc) for 21 days (from 6/4/2025 to 6/24/2025). LVN 2 stated these medications were supplements that helped healthy tissue growth and were important for healing Resident 51's PU. LVN 2 stated the RNS 1 was responsible for adding new orders in the MAR, but LVNs should check the MAR and match the MAR with the orders to ensure accuracy of mediation administration. During an interview with the DON on 6/26/2025, at 10:37 AM, the DON stated nurses could give residents milk, crackers, or apple sauce with medications that required to be given with food. The DON stated that half a teaspoon of apple sauce was not considered enough food to give with medications that needed to be given with food. The DON stated it was important to administer medications with food to minimize adverse effects of the medicine such as nausea and upset stomach. The DON stated that when the residents experienced the adverse effects from the medications, they could begin refusing medications and this could delay wound healing and illness recovery. During a concurrent review of Resident 51's medication cards and interview on 6/26/2025 at 2:43 PM, with Dispensing Pharmacist (Pharm 1), the following medication cards contained instructions to take with food: 1. Glimepiride: Administer with food. 2. Potassium Chloride ER: Administer with or after meals with 4-8 ounces of water. 3. Xarelto: Administer with food. Pharm 1 stated Potassium Chloride ER could not be crushed and Xarelto had to be taken with food. Pharm 1 stated that when Xarelto was not taken with food, Resident 51 could experience a higher medication absorption. Pharm 1 stated Glimepiride should be given with a big meal, usually breakfast, because the medication could cause a drop in blood sugar. A review of the facility's P&P titled, "Medication - Administration," dated 11/1/2017, indicated, "if the medication is to be crushed, a physician order is required." The P&P indicated “the licensed nurses must know the following information about any medication they are administering including medications' side effects and adverse effects.” A review of the facility's P&P titled, "Pain Management," dated 11/1/2017, = indicated, “the licensed nurse will administer pain medication as ordered and document all medications administered on the MAR.” The P&P indicated “nursing staff will implement timely interventions to reduce the increase in severity of pain.” A review of the facility's P&P titled, "Physician Orders," 5/1/2019, = indicated to ensure that all physician orders are complete and accurate. The P&P indicated the licensed nurse receiving the order will be responsible for documenting and implementing the order. The facility failed to follow its P&Ps titled, "Physician Orders," "Pain Management," "Medication - Administration," and the manufacture specifications on the medication card to prevent significant medication errors for Resident 51 by failing to ensure: A. LVN 2 followed the medication card for Potassium Chloride indicating “Do not crush,” and followed MD 1's orders indicating to administer medications with food/water. B. Pain medication was administered before Resident 51’s wound care treatment and Ascorbic Acid and Zinc were administered from 6/4/2025 to 6/24/2025 (omitted for 21 days). As a result of these failures, Resident 51 did not receive medications in accordance with the physicians' orders, the facility's P&Ps, or the specifications on the medication card. These failures placed Resident 51 at risk for significant medical complications including pain and delayed wound healing. The above violation, jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 51.