Health inspection·May 29, 2025

F760 Code of Federal Regulations, Title 42, Section §483.45(f)(2) The facility must ensure that its- §483.45(f)(2) Residents are free of any significant medication errors. California Code of Regulations, Title 22 Section § 72313 Nursing Service -Administration of Medications and Treatments (2) Medications and treatments shall be administered as prescribed California Code of Regulations, Title 22, Section 72311. Nursing Service - General (a)Nursing service shall include, but not be limited to, the following: (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. 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 4/15/2025, the California Department of Public Health (CDPH) conducted an unannounced annual recertification survey at the facility. As a result of the investigation, the CDPH determined the facility failed to hold Epogen injections when Residents 35 and 89's hemoglobin (Hgb) level was more than (>) 10 grams per deciliter (g/dl) as indicated in Residents 35 and 89's Physician’s Orders (PO). As a result, Resident 35 received 19 unnecessary doses of Epogen injections from 2/18/2025 to 4/17/2025 (2/20/2025, 2/22/2025, 2/25/2025, 2/27/2025, 3/1/2025, 3/6/2025, 3/8/2025, 3/11/2025, 3/13/2025, 3/15/2025, 3/18/2025, 3/20/2025, 3/22/2025, 3/25/2025, 3/29/2025, 4/1/2025, 4/3/2025, 4/8/2025, and 4/12/2025) when Resident 35's Hgb level was at 11.5 g/dl. Resident 89 received three unnecessary doses of Epogen injections from 1/4/2025 to 2/17/2025 (1/20/2025, 1/31/2025 and 2/7/2025) when Resident 89's Hgb levels were at 12.3 g/dl and 12.9 g/dl. These violations resulted in Residents 35 and 89 received unnecessary medications (medications that are taken when they're not actually needed, often leading to potential harm, wasted resources, and reduced patient satisfaction), placed Residents 35 and 89 at risk to experience adverse side effects such as polycythemia and hypercoagulability, stroke, and heart attack from receiving excessive doses of Epogen injections, and had the potential to result in serious harm, injury or death from these significant medication errors. 1. A review of Resident 35's Admission Record (AR) indicated the facility admitted Resident 35, a 70-year-old female on 12/6/2024 and readmitted on 2/9/2025 with diagnoses including End Stage Renal Disease, dependence on renal dialysis and anemia. A review of Resident 35's untitled Care Plan revised on 1/7/2025 indicated for licensed nurses to administer Resident 35's medications as ordered. A review of Resident 35's PO dated 2/17/2025 indicated for licensed nurses to Administer Epogen injection solution, 10000 units per millimeter (u/ml), to inject subcutaneously in the evening every Tuesday, Thursday and Saturday for anemia, and hold if Resident 35's Hgb was > 10 g/dl. A review of Resident 35's Laboratory Report (LR) dated 2/18/2025 indicated Resident 35's Hgb level was 11.5 g/dl. During a concurrent review of Resident 35's Medication Administration Record (MAR) dated from 2/2/2025 to 4/17/2025, and interview with Licensed Vocational Nurse 6 (LVN 6) on 4/17/2025 at 4:39 pm, the MAR dated from 2/2/2025 to 4/17/2025 indicated to administer Epogen injection solution 10000 u/ml, inject 10000 units subcutaneously in the evening on Tuesday, Thursday and Saturday for amenia, hold if Hgb above 10 mg/dl. The MAR indicated Resident 35 received a total of 19 doses of Epogen injections (2/20/2025, 2/22/2025, 2/25/2025, 2/27/2025, 3/1/2025, 3/6/2025, 3/8/2025, 3/11/2025, 3/13/2025, 3/15/2025, 3/18/2025, 3/20/2025, 3/22/2025, 3/25/2025, 3/29/2025, 4/1/2025, 4/3/2025, 4/8/2025, and 4/12/2025). The MAR indicated Resident 35's Hgb level was 11.5 g/dl. LVN 6 stated, LVN 6 administered Epogen injection to Resident 35 on 2/20/2025, 2/25/2025, 3/13/2025, 3/15/2025, 3/20/2025, 4/1/2025 and 4/12/2025. LVN 6 stated, Resident 35's most recent complete blood count (CBC) result was reported on 2/18/2025 and Resident 35's Hgb level was 11.5 g/dl. LVN 6 stated 11.5 g/dl was above the physician's order to give Epogen injection to Resident 35. LVN 6 stated, Resident 35's PO was to hold Epogen injection when Resident 35's Hgb was > 10 g/dL. LVN 6 stated LVN 6 did not check Resident 35's PO before administering Epogen injections to Resident 35. LVN 6 stated, LVN 6 need to follow Resident 35's PO and hold Epogen injections when Resident 35's Hgb was at 11.5 g/dL. LVN 6 stated that administering excessive doses of Epogen injections would increase Resident 35's blood Hgb level that could cause headache, dizziness, elevated blood pressure and polycythemia. LVN 6 stated, before Epogen administration, LVN 6 needed to check the right patient, right medication, right dose, right route, right time and relevant special instructions of the medication. During a telephone interview with the facility's Medical Director (MD) on 4/18/2025 at 10:36 am, the MD stated the facility had residents receiving Epogen injections (Residents 35, 89 and 244) with a standing to hold Epogen injection when the Residents' (Residents 35, 89 and 244's) Hgb level was more than 10 g/dl. The MD stated the risk for Resident 35 receiving excessive doses of Epogen was elevated blood Hgb level and could result in polycythemia and hypercoagulability. During a telephone interview with Resident 35’s Nephrologist (Neph 1) on 4/18/2025 at 10:50 am, Neph 1 stated, Resident 35 was under Neph 1's care. Neph 1 stated, Resident 35's Epogen injections should be administered at Dialysis Center (DC) 1 during Resident 35's dialysis days instead of at the facility because there was a standing order for DC 1 to check Resident 35's Hgb twice a month. Neph 1 stated licensed nurses needed to stop giving Epogen injection when Resident 35's Hgb level was >10 g/dl. Neph 1 stated that when residents receive excessive doses of Epogen injections the Hgb level would elevate and could result in stroke and heart attack. During a concurrent review of Resident 35's MAR, dated from 2/2/2025 to 4/17/2025 and interview with LVN 7 on 4/18/2025 at 1:24 pm, the MAR dated from 2/2/2025 to 4/17/2025 indicated to administer Epogen injection solution 10000 u/ml, inject 10000 units subcutaneously in the evening on Tuesday, Thursday and Saturday for amenia, hold if Hgb above 10 mg/dl. The MAR indicated Resident 35 received a total of 19 doses of Epogen injection (2/20/2025, 2/22/2025, 2/25/2025, 2/27/2025, 3/1/2025, 3/6/2025, 3/8/2025, 3/11/2025, 3/13/2025, 3/15/2025, 3/18/2025, 3/20/2025, 3/22/2025, 3/25/2025, 3/29/2025, 4/1/2025, 4/3/2025 4/8/2025, and 4/12/2025). The MAR indicated Resident 35's Hgb level was 11.5 g/dL. LVN 7 stated, LVN 7 administered Epogen injection to Resident 35 on 2/22/2025, 2/27/2025, 3/1/2025, 3/6/2025, 3/8/2025, 3/11/2025, 3/18/2025, 3/25/2025, 3/29/2025, 4/3/2025 and 4/8/2025 when Resident 35's Hgb level was 11.5 g/dl. LVN 7 stated Resident 35's PO was to hold Epogen injection when Resident 35's Hgb level was > 10 g/dl, but LVN 7 did not read nor check Resident 35's PO prior to administrating Epogen injections to Resident 35. LVN 7 stated LVN 7 needed to hold Resident 35's Epogen injections when the resident's Hgb level was 11.5 g/dl. LVN 7 stated, "these (mistakes) were considered medication errors." LVN 7 stated high Hgb level could cause Resident 35 to have blood clots and possible stroke. During a telephone interview with the Clinical Coordinator (CC) from DC 1 on 4/19/2025 at 9:30 am, the CC stated possible risks for high Hgb included blood clot, heart attack and stroke. A review of DC 1's laboratory results for Resident 35 from 1/1/2025 to 4/18/2025 indicated Resident 35's Hgb level was at 10.7 g/dl on 1/27/2025; 11.5 g/dl on 2/24/2025; 12.4 g/dl on 3/31/2025, and 12.5 g/dl on 4/7/2025. 2. A review of Resident 89's AR indicated the facility admitted Resident 89, a 64-year-old male, on 9/26/2024 and readmitted Resident 89 on 12/30/2024, with diagnoses including kidney transplant and anemia. A review of Resident 89's most current LR dated 12/22/2024 indicated Resident 89's Hgb level was 12.9 g/dl. A review of Resident 89's PO dated 1/4/2025 indicated for licensed nurses to administer Epogen injection solution 10000 u/ml, inject subcutaneously in the morning, every Monday, Wednesday and Friday for anemia, hold if Hgb > 10 g/dl. A review of Resident 89's untitled CP dated 1/17/2025 indicated for licensed nurses to administer Resident 89's medications as ordered. During a concurrent interview with LVN 3 and review of Resident 89's MAR dated from 1/20/2025 to 2/28/2025, on 4/18/2025 at 1:40 pm, the MAR dated from 1/20/2025 to 2/28/2025, indicated to administer Epogen injection solution 10000 u/ml, inject 10000 units subcutaneously in the morning on Monday, Wednesday and Friday for amenia, hold if Hgb above 10 mg/dl. The MAR indicated Resident 89 received Epogen injections on 1/20/2025, 1/31/2025 and 2/7/2025. The MAR indicated Resident 89's Hgb level was 12.3 g/dL. LVN 3 stated, LVN 3 administered Epogen injections to Resident 89 on 1/20/2025 without checking Resident 89's latest Hgb level. LVN 3 stated based on the result of Resident 89's Hgb on 12/22/2024 (12.9 mg/dl), Resident 89 did not need the Epogen injection on 1/20/2025. LVN 3 stated Resident 89's Epogen injections "should have been held." LVN 3 stated, LVN 3 also administered Epogen injection to Resident 89 on 2/7/2025 when Resident 89's Hgb level was at 12.3 g/dl. LVN 3 stated LVN 3 did not read Resident 89's PO accurately before administering Epogen injections to Resident 89. LVN 3 stated, high Hgb level could result in blood clots, heart attack and strokes to Resident 89. During an interview on 4/19/2025 at 9:48 am, with the DON, the DON stated, "It was a medication error." The DON stated the facility did not follow the physicians' order and administered Epoetin injections to Residents 35 and 89 when Residents 35 and 89's Hgb level were above the prescribed parameter (specific instructions to hold when Hgb >10 mg/dl). The DON stated, licensed nurses needed to check Residents 35 and 89's most recent/current Hgb level before administering Epogen injections to Residents 35 and 89. The DON stated, when administering medication, licenses nurses needed to follow the principle of "Five Rights" including right patient, right drug, right dose, right route and right time. The DON stated licensed nurses needed to double check any medication ordered with a parameter to prevent medication errors. The DON stated that high levels of Hgb would cause serious side effects including blood clots, heart attack and stroke. A review of the facility's Policy and Procedure (P&P) titled, "Administering Medications," dated 3/2023 indicated "Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame." A review of the facility's P&P titled, "Adverse Consequences and Medication Errors," dated 3/2023 indicated "A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional providing services." The facility failed to hold Epogen injections when Residents 35 and 89's Hgb level was >10 grams per deciliter as indicated in Residents 35 and 89's PO. As a result, Resident 35 received 19 unnecessary doses of Epogen injections from 2/18/2025 to 4/17/2025 (2/20/2025, 2/22/2025, 2/25/2025, 2/27/2025, 3/1/2025, 3/6/2025, 3/8/2025, 3/11/2025, 3/13/2025, 3/15/2025, 3/18/2025, 3/20/2025, 3/22/2025, 3/25/2025, 3/29/2025, 4/1/2025, 4/3/2025, 4/8/2025, and 4/12/2025) when Resident 35's Hgb level was at 11.5 g/dl. Resident 89 received three unnecessary doses of Epogen injections from 1/4/2025 to 2/17/2025 (1/20/2025, 1/31/2025 and 2/7/2025) when Resident 89's Hgb levels were at 12.3 g/dl and 12.9 g/dl. These violations resulted in Residents 35 and 89 received unnecessary medications, placed Residents 35 and 89 at risk to experience adverse side effects such as polycythemia and hypercoagulability, stroke, and heart attack from receiving excessive doses of Epogen injections, and had the potential to result in serious harm, injury or death from these significant medication errors. These violations, jointly, separately, or in any combination, had a direct or immediate effect to the health, safety, or security of Residents 35 and 89.