Rio Hondo Subacute & Nursing Center

F-F755)

This deficient practice of failing to act upon special handling of controlled medication irregularities (potential issues with a resident's medication regimen) identified by the consultant pharmacist during the Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) increased the potential for exposure of fentanyl by residents, staff, and visitors and could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) such as respiratory depression (breathing disorder), hospitalization , or death.

Findings:

During a review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included quadriplegia (a form of paralysis that affects all four limbs), chronic (long-term) pain syndrome, respiratory failure (difficulty breathing on your own) with hypoxia (low oxygen levels in the blood), and opioid (narcotics used to treat persistent or severe pain) dependence (when you need one or more drugs to function).

During a review of Resident 2 ' s History and Physical (H&P), dated 7/29/2024, the H&P indicated, Resident 2 had the mental capacity to understand and make medical decisions.

During a review of the Minimum Data Set (MDS - a comprehensive resident assessment and care screening tool) dated 07/11/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 2 required setup or clean-up assistance for eating, required partial or moderate staff assistance with oral hygiene and personal hygiene, and substantial or total dependence on staff assistance for toileting, bathing, dressing.

During a review of Resident 2's Order Listing Report indicated the following physician orders on 7/28/23 for Resident 2:

- fentanyl Transdermal Patch 72 Hour 25 micrograms (mcg unit of measure) per hour (HR), instructions indicated, apply one patch transdermally every 72 hours for chronic pain management rotate site every application administration

- check placement of fentanyl patch every 72 hours

- fentanyl patch removal and destruction verified by second nurse every 72 hours

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0756 During a concurrent interview and record review on 8/2/2024 at 5:33 PM with Director of Nursing (DON), Resident 2 ' s form titled, Controlled Drug Record for Duragesic/ Fentanyl Patch, from 5/5/2024 through Level of Harm - Minimal harm or 7/31/2024 was reviewed, that indicated one nurse initialed for the removal of the fentanyl patch. DON stated potential for actual harm that Licensed Vocational Nurses (LVN)s are disposing of the fentanyl patches without a witness. DON stated

the LVNs are not giving the used fentanyl patches to the DON for disposal to be done with the Pharmacist Residents Affected - Few Consultant. DON stated, This was not happening. DON stated that the Pharmacist Consultant did not notice

during the monthly controlled drug disposal that there was no fentanyl being disposed of or given to the DON since 2023, the nurses have been destroying the fentanyl in the trash. DON stated that the DON was not aware of the disposal of fentanyl by the nurses or that the nurses was throwing the old fentanyl patches into

the regular trash. DON stated that the controlled medication fentanyl can be picked up by staff, other residents, or visitors when the fentanyl patches are removed, and others maybe accidentally exposed to the adverse effects of fentanyl that could lead to hospitalization or death.

During concurrent interview and record review on 8/2/24 at 6:22 PM, with DON, Resident 2 ' s pharmacist Monthly Regimen Review (MRR) dated 6/1/2024 and 6/20/2024 was reviewed. Resident 2 ' s MRR documentation included a recommendation to the facility that indicated, Please document removal of the Fentanyl patch and the old patch needs to be kept in the narcotic drawer in a labeled container, counted q shift and prepared to be destroyed with the other narcotics by the DON. DON stated that the Pharmacist Consultant (Pharm 2) MRR recommendation to document the removal of each fentanyl patch and to secure

the used patches in a labeled container, locked in a controlled drawer, and then to give the used fentanyl patches to the DON for destruction was not followed. DON stated there was a system failure.

During a telephone interview on 8/2/2024 with the facility ' s dispensing pharmacist (Pharm 1) in the presence of the DON, Pharm 1 stated, the facility ' s Consultant Pharmacist (Pharm 2) provides the facility with clinical advise and it depends upon the facility ' s policy as to who does the final disposition and destruction of the fentanyl patches. Pharm 1 stated the fentanyl patch should never be disposed of in the regular trash as there may still be active medication in the patch and others may be exposed to the effects of fentanyl and could experience adverse reactions.

During a review of DailyMed (the official provider of U.S. Food and Drug Administration [FDA] label information, manufacturer ' s package inserts), updated 05/2024, included a Fentanyl Box Warning (the strongest warning that the FDA requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects) indicated, Accidental exposure of even one dose of fentanyl transdermal system, especially in children, can result in a fatal overdose of fentanyl [see Warnings and Precautions (5.3)]. Deaths due to an overdose of fentanyl have occurred when children and adults were accidentally exposed to fentanyl transdermal system. Strict adherence to the recommended handling and disposal instructions is of the utmost importance to prevent accidental exposure Warnings and Precautions 5.3 . Accidental Exposure .A considerable amount of active fentanyl remains in fentanyl transdermal system even after use as directed. Death and other serious medical problems have occurred when children and adults were accidentally exposed to fentanyl transdermal system.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0756 During a review of the facility ' s policy and procedure (P&P) titled, Controlled Medication Disposal, dated 01/2013, the P&P indicated, Fentanyl patches when removed from the resident shall be properly identified, Level of Harm - Minimal harm or stored, and accounted for consistent with facility requirements for monitoring of controlled medication potential for actual harm supplies. When the resident is discharged , the order discontinued, or the current prescription supply of new patches has been used, the remaining removed patches shall be provided for disposition. Removed patches Residents Affected - Few shall be provided to the director of nursing or designated facility registered nurse for proper storage until disposal as outlined under the procedure for disposal of Schedule II-V controlled substances .Schedule II-V controlled substances remaining in the facility after a resident has been discharged , or the order discontinued, are disposed of in the facility by the director of nursing or designated facility registered nurse in conjunction with the pharmacist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47467

Residents Affected - Few Based on observation, interview, and record review, the facility failed to implement the facility ' s policy and procedure by failing to provide clean and sanitary environment and ensure the oxygen nasal cannula (NC, a flexible tube that provides oxygen through the nose) was not reused after it was observed on the floor for one of two sampled residents (Resident 1).

This failure had a potential to result in Resident 1 ' s respiratory infection.

Findings:

During a review of Resident 1 ' s Admission Record, indicated Resident 1 was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis that included cellulitis (an infection of the deeper layers of skin and the underlying tissue), type 2 diabetes (condition that results in too much sugar circulating in the blood), and malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients).

During a review of Resident 1 ' s History and Physical, dated 6/5/2024, indicatedResident 1 had capacity to understand and make decisions.

During a review of Resident 1 ' s Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 6/10/2024, indicatedResident 1 ' s cognition was intact (able to think, remember, and reason) and needed moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) in oral hygiene and personal hygiene.

During a review of Resident 1 ' s Order Summary Report, dated 1/31/2024, indicatedResident 1 had a physician order for oxygen at 2 LPM [Litters (unit of volume) per minute (unit of time)] via NC to keep oxygen saturation (measures how much oxygen blood carries in comparison to its full capacity) above 92% as needed.

During a concurrent observation and interview on 8/2/2024 at 8:45 AM with Resident 1 in his room, the resident was observed lying in bed. Resident 1 ' s NC with the marked date (date when the NC was last changed) of 7/24/2024 was on the floor. Resident 1 stated, he did not know why his NC was on the floor.

During an observation on 8/2/2024 at 9:40 AM in Resident 1 ' s room, Resident 1 was receiving oxygen at 2 LPM via a NC that had a marked date of 7/24/2024.

During an interview on 8/2/2024 at 9:47 AM with the Registered Nurse (RN) 1, RN 1 stated, Resident 1 ' s Certified Nurse Assistant (CNA) 1 was assisting Resident 1 with cleaning and put Resident 1 back on oxygen without letting the nurses know. RN 1 stated, the NC supposed to be discarded because it was on the floor, which could lead to respiratory infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0921 During an interview on 8/2/2024 at 10:40 AM with CNA 1, CNA 1 stated, when she was assisting with cleaning up Resident 1, Resident 1 stated that he needed his oxygen, so CNA 1 put his NC back on and Level of Harm - Minimal harm or forgot that it was on the floor. CNA 1 stated, she should have notified the licensed nurse to have the NC potential for actual harm replaced.

Residents Affected - Few During an interview on 8/2/2024 at 5:30 PM with the Director of Nurses (DON), the DON stated, CNA 1 should have notified the licensed nurse that Resident 1 ' s NC was on the floor because the NC was contaminated. The DON stated, Resident 1 could be at risk for respiratory infection due to reusing contaminated NC.

During a review of the facility ' s policy and procedure (P&P) titled, Changing of Nasal Cannula/Oxygen Tubing, undated, indicated it is the policy of this facility to change the nasal cannula and oxygen tubing weekly and as needed, if the nasal cannula is viability soiled or damage.

During a review of the facility ' s P&P titled, Policies and Procedures - Infection Prevention and Control, revised 12/2023, indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 18 056487

F-F756)

Findings:

During a review of Resident 2's Admission Record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included quadriplegia (a form of paralysis that affects all four limbs), chronic (long-term) pain syndrome, respiratory failure (difficulty breathing on your own) with hypoxia (low oxygen levels in the blood), and opioid (narcotics used to treat persistent or severe pain) dependence (when you need one or more drugs to function).

During a review of Resident 2's History and Physical (H&P), dated 7/29/2024, the H&P indicated, Resident 2 had the mental capacity to understand and make medical decisions.

During a review of the Minimum Data Set (MDS - a comprehensive resident assessment and care screening tool) dated 07/11/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 2 required setup or clean-up assistance for eating, required partial or moderate staff assistance with oral hygiene and personal hygiene, and substantial or total dependence on staff assistance for toileting, bathing, dressing.

During a review of Resident 2's Order Summary Report with active orders as of 7/31/2024, included, but not limited to the following physician orders dated 7/28/23 for Resident 2:

1. Fentanyl Transdermal Patch 72 Hour 25 micrograms (mcg unit of measure) per hour (HR), instructions indicated to Apply 1 patch transdermally every 72 hours

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0755 for Chronic Pain Management Rotate site every application Administration and destruction by Nurse 1, HOLD if SBP (Systolic blood pressure, the pressure exerted when the heartbeats) < (less than) 110 Level of Harm - Minimal harm or millimeters of mercury (mm Hg. Unit of measure) or HR (heart rate, the number of times the heart beats in a potential for actual harm minute) <65 beats per minute (bpm) or RR (respiration rate) <14 breaths per minute or 02 (blood oxygen saturation is the amount of oxygen circulating in the blood) <93% (normal range 95% and 100%) and remove Residents Affected - Some per schedule

2. Check Placement of Fentanyl Patch every 72 hours

3. Fentanyl Patch Removal and Destruction verified by 2nd Nurse every 72 hours

4. Oxycodone (narcotic/controlled substance with a high risk for addiction and dependence used to treat severe pain) HCI Oral Tablet 30 MG, instructions indicated to Give 1 tablet by mouth every 6 hours as needed (PRN) for SEVERE Pain (8-10) HOLD if SBP <110 or HR, <60, or RR <12, or 02 <93%

During a review of Resident 2's Care Plans indicated the following Care Plans for:

a. Resident's PRN medications given earlier than due time, dated 4/22/2024, goal indicated, Resident will have no complication related to receiving pain medication earlier, interventions indicated, Monitor for non-verbal signs/symptoms of pain and medicate as ordered. Evaluate pain quality.

b. Resident exhibits or is at risk for alterations in comfort. Resident has medications with black box warning, fentanyl transdermal patch and oxycodone oral tablet, dated initiated 7/23/2023, date revised 4/18/2024, goal indicated, Resident will not experience pain . Resident will achieve acceptable level of pain control . interventions indicated, Oxycodone exposes patients and other users to the risk of opioid addiction, abuse, and misuse, which can lead to overdose and death .Opioid analgesic risk evaluation and mitigation strategy (REMS). To ensure that the benefits of opioid analgesics outweigh the risks of addition, abuse, and misuse,

the FDA has required a REMS for these products .Health care providers are strongly encouraged to complete a REMS-compliant education program and counsel patients and/or their caregivers, with every prescription, on safe use, serious risks, storage, and disposal of these products .

During a review of Resident 2 ' s MARs for June 2024 and July 2024, Resident 2 ' s MARs indicated the resident ' s fentanyl patch application site was not rotated with each application. Resident 2 ' s MAR indicated on:

6/22/2024 at 9:08 PM remove fentanyl patch - Abdomen RLQ (right lower quadrant)

6/22/2024 at 9:09 PM apply fentanyl patch - Abdomen RLQ

6/25/2024 at 8:58 PM remove fentanyl patch - Abdomen RLQ

6/25/2024 at 8:58 PM apply fentanyl patch - Abdomen RLQ

7/10/2024 at 10:48 PM remove fentanyl patch - Chest - right

7/10/2024 at 10:48 PM apply fentanyl patch - Chest - right

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0755 7/13/2024 at 3:46 PM apply fentanyl patch - Chest - left

Level of Harm - Minimal harm or 7/13/2024 at 6:09 PM remove fentanyl patch - Chest - left potential for actual harm 7/22/2024 at 6:28 PM remove fentanyl patch - Chest - left Residents Affected - Some 7/22/2024 at 10:18 PM apply fentanyl patch - Chest - left

7/25/2024 at 10:27 PM remove fentanyl patch - Chest - left

7/25/2024 at 10:28 PM apply fentanyl patch - Chest - left

7/28/2024 at 3:45 PM remove fentanyl patch - Chest - left

7/28/2024 at 3:46 PM apply fentanyl patch - Chest - left

7/31/2024 at 3:45 PM remove fentanyl patch - Chest - left

7/31/2024 at 3:46 PM apply fentanyl patch - Chest - left

During a review of Resident 2 ' s MARs for June 2024 and July 2024, Resident 2 ' s MARs indicated the resident was administered PRN oxycodone 30 mg for severe pain 82 doses in June 2024 and 86 doses in July 2024.

During an interview on 8/2/2024 at 12:24 PM, with a Licensed Vocational Nurse (LVN) 1 on Nursing Station 2, LVN 1 stated that resident had a pain level of 8 out of 10 and she had just administered to Resident 2 an as needed pain medication oxycodone for spine pain. LVN 2 stated that Resident 2 ask for his PRN pain medication oxycodone about every six hours every day.

During an interview on 8/2/2024 at 12:27 PM, with Resident 2 in the presence of LVN 1 at Resident 2 ' s bedside, Resident 2 stated the fentanyl patch fell off last night (8/1/2024) when taking off a shirt. Resident 2 stated the fentanyl patch irritates his skin and he takes off the patch or the patch falls off. Resident 2 stated when the patch is taken off or falls off, he places the patch on the bedside table, or stick the fentanyl patch to

a water bottle or soda can, where he can see it. Resident 2 stated when the nurse puts on a new patch, the nurse will take away the old patch or he will give the nurse the fentanyl patch that fell off. Resident 2 looked toward the bedside table and stated the fentanyl patch that fell off last night was no longer there. Resident 2 stated that he believes housekeeping took the fentanyl patch that he placed on the beside table away with

the trash.

During a concurrent interview and observation on 8/2/2024 at 12:35 PM, with LVN 1 at Resident 2 ' s bedside, LVN 1 stated that she did not know that Resident 2 wears a fentanyl patch and did not know to look for it. LVN 1 looked at Resident 2 ' s upper body and chest and stated that there was no fentanyl patch on

the resident. Resident 2 confirmed that he did not have a fentanyl patch on today, 8/2/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0755 During a concurrent observation and interview on 8/2/2024 at 2:54 PM, with LVN 3 on Nursing Station 2, at Medication Cart 1, inside of Medication Cart 1 was two boxes of Fentanyl Transdermal Patch 72 Hour 25 Level of Harm - Minimal harm or mcg/hr labeled for Resident 2, one box was unopened and labeled to contain five patches, the second box potential for actual harm was open, and two patches was observed inside. LVN 3 stated the steps for applying and removing the fentanyl patch was as follow: Residents Affected - Some a. check the resident ' s physician order

b. review the Medication Administration Record (MAR)

c. put on a pair of gloves and remove the old (used) fentanyl patch and put away to give to the Director of Nursing (DON)

d. clean the new application site, rotate the site, use a new location to apply the fentanyl patch, date and sign

the new fentanyl patch

e. has to be two LVNs to sign for the removal of the patch from the resident, the LVN ' s must be together to see the resident, remove the old fentanyl patch and replace with a new fentanyl patch

f. put the old (used) patch inside of a plastic pouch and give to the RN or DON

During a concurrent interview and record review on 8/2/2024 at 3:10 PM, with LVN 3, Resident 2 ' s July 2024 MAR was reviewed that indicated Resident 2 ' s fentanyl patch was applied to the left chest every 72 hours, on 7/19/2024, 7/22/2024, 7/25/2024, 7/28/2024, and 7/31/2024. LVN 3 stated the documentation does not indicate that the fentanyl patches are being rotated with each new application and the nurses should check the site for skin irritation. LVN 3 stated the application site for fentanyl should have been rotated.

During an interview on 8/2/2024 at 3:17 PM, with the DON, DON stated, The licensed nurses have not given me any used fentanyl patches for disposal. DON stated that the licensed nurses have not been following the facility ' s policy to remove the fentanyl patches with 2 nurses and then give the used fentanyl patch to the DON for disposal/destruction. DON stated the reason to have two nurses remove the fentanyl patch is also to check to make sure they apply the fentanyl patch to a different location from the previous site to prevent

the resident from having an adverse reaction or causing irritation to the skin. DON stated the licensed nurses must rotate the site with each application.

During a concurrent interview and record review on 8/2/2024 at 3:24 PM, with DON, Resident 2 ' s Controlled Drug Record for Duragesic/Fentanyl Patch (CDR) between 5/5/2024 through 7/31/2024, and the DON ' s monthly controlled drug destruction records were reviewed. DON stated there was one nurse ' s initial documented on Resident 2 ' s CDR for the removal of the fentanyl patch and not two nurse ' s initials as ordered by the physician and required by the facility ' s policy. DON stated there was no documentation that

she received any used fentanyl patches and there was no documentation of the destruction of fentanyl patches by the DON with the facility ' s consultant pharmacist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0755 During a concurrent interview and record review on 8/2/2024 at 3:45 PM, with DON, Resident 2 ' s July 2024 and July 2024 CDR were reviewed, and there was a discrepancy between the MAR and the CDR. The MAR Level of Harm - Minimal harm or documented administration of fentanyl on 7/22/2024 and 7/25/2024 and there was no documentation on the potential for actual harm CDR that fentanyl was pulled for administration on 7/22/2024 or 7/25/2024. DON could not explain the discrepancies between Resident 2 ' s MAR and CDR and stated that it could be a missed dose or medication Residents Affected - Some error. DON stated, The nurses do not bring the removed fentanyl patches to me to review. DON stated that

she could not be sure if the fentanyl patch for Resident 2 was administered to the resident on 7/22/2024 an d7/25/2024, missed, or was a medication error. DON stated that she have not done any reconciliation of any fentanyl patches to ensure accuracy from receipt to resident administration to disposal and destruction to account for each fentanyl patch. DON stated that she was not overseeing the handling, storage, or disposal of fentanyl patches in the facility and have no record of the disposal of fentanyl. DON stated that today, 8/2/2024 was the first time she reviewed the policy on fentanyl.

During an interview on 8/2/2024 at 4:15 PM, with LVN 4 and LVN 5, LVN 4 stated when removing fentanyl patch from Resident 2 LVN 4 would put on gloves, remove the used fentanyl patch from the resident, place

the patch inside of the glove, remove the glove and throw both the glove and the patch together in the trash can and that there was no nurse to witness the disposal of the fentanyl patch. LVN 5 stated that LVN 5 would remove and disposal of the fentanyl patch into the trash without a witness. LVN 4 stated need more training. LVN 5 stated there was no orientation provided on how to handle controlled medications. LVN 4 and LVN 5 each stated that they did not know locations other than the chest could be used as alternative sites of application for fentanyl. LVN 5 stated that LVN 5 applied the fentanyl patch to left side of Resident 2 ' s chest

on 7/28/2024 and again on 7/31/2024 without rotating the site every application.

During an interview on 8/2/2024 at 4:22 PM, with LVN 5, LVN 5 stated on 7/28/2024 that LVN 5 saw a used fentanyl patch on a water bottle beside Resident 2 ' s bed and LVN 5 stated she threw the used fentanyl patch away in the trash.

During a concurrent interview and record review on 8/2/2024 at 4:33 PM, with LVN 4, Resident 2 ' s July MAR and July CDR for fentanyl was reviewed. LVN 4 stated on 7/22/2024 that LVN 4 signed on Resident 2 ' s MAR for fentanyl patch by mistake but did not apply a fentanyl patch to Resident 2 on 7/22/2024.

During a concurrent interview and record review on 8/2/2024 at 4:55 PM, with LVN 6, Resident 2 ' s July MAR and July CDR for fentanyl was reviewed. LVN 6 stated on 7/25/2024 that LVN 6 signed on Resident 2 ' s MAR for fentanyl patch by mistake but did not apply a fentanyl patch to Resident 2 on 7/25/2024.

During an interview on 8/2/2024 at 5:33 PM, with DON, DON stated, missed the fentanyl medication errors for Resident 2 on 7/22/2024 and 7/25/2024 that two nurses signed for Resident 2 ' s fentanyl patch and the medication was not administered to the resident. DON stated that she was not aware that the nurses were throwing the used fentanyl patches in the regular trash. DON stated the used fentanyl patches could be picked up by anyone, the staff, other residents, or visitors when the fentanyl patches are removed by the resident and placed at the resident ' s bedside or thrown into regular trash and could cause others to experience adverse reactions which could lead to hospitalization or death.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0755 During a telephone interview on 8/2/2024 with the facility ' s dispensing pharmacist (Pharm 1) in the presence of the DON, Pharm 1 stated, the facility ' s Consultant Pharmacist (Pharm 2) provides the facility Level of Harm - Minimal harm or with clinical advise and it depends upon the facility ' s policy as to who does the final disposition and potential for actual harm destruction of the fentanyl patches. Pharm 1 stated the fentanyl patch should never be disposed of in the regular trash as there may still be active medication in the patch and others may be exposed to the effects of Residents Affected - Some fentanyl and could experience adverse reactions.

During a review of DailyMed (the official provider of U.S. Food and Drug Administration [FDA] label information, manufacturer ' s package inserts), updated 05/2024, included a Fentanyl Box Warning (the strongest warning that the FDA requires, and signifies that medical studies indicate that the drug carries a significant risk of serious or even life-threatening adverse effects) indicated, Accidental exposure of even one dose of fentanyl transdermal system, especially in children, can result in a fatal overdose of fentanyl [see Warnings and Precautions (5.3)]. Deaths due to an overdose of fentanyl have occurred when children and adults were accidentally exposed to fentanyl transdermal system. Strict adherence to the recommended handling and disposal instructions is of the utmost importance to prevent accidental exposure Warnings and Precautions 5.3 . Accidental Exposure .A considerable amount of active fentanyl remains in fentanyl transdermal system even after use as directed. Death and other serious medical problems have occurred when children and adults were accidentally exposed to fentanyl transdermal system.

During a review of the facility ' s policy and procedure (P&P) titled, Controlled Medication Disposal, dated 01/2013, the P&P indicated, Fentanyl patches when removed from the resident shall be properly identified, stored, and accounted for consistent with facility requirements for monitoring of controlled medication supplies. When the resident is discharged , the order discontinued, or the current prescription supply of new patches has been used, the remaining removed patches shall be provided for disposition. Removed patches shall be provided to the director of nursing or designated facility registered nurse for proper storage until disposal as outlined under the procedure for disposal of Schedule II-V controlled substances .Schedule II-V controlled substances remaining in the facility after a resident has been discharged , or the order discontinued, are disposed of in the facility by the director of nursing or designated facility registered nurse in conjunction with the pharmacist.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 18 056487 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056487 B. Wing 08/02/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Rio Hondo Subacute & Nursing Center 273 E Beverly Boulevard Montebello, CA 90640

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 0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31333

Residents Affected - Few Based on interview and record review, the facility failed to act upon the consultant pharmacist ' s recommendations from 6/1/2024 and 6/20/2024 to ensure accountability of fentanyl (narcotic/controlled substance with a high risk for addiction and dependence used to treat severe pain) Transdermal (supplying a medication in a form for absorption through the skin into the bloodstream) Patch, removal, and disposal for one of two Resident (Resident 2).

(Cross Reference