Health inspection·February 4, 2025

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the pharmacy consultant identified irregularities during a medication regimen review for one of three residents (Resident 1) reviewed for medications. In addition, the facility failed to ensure a pharmacy recommendation for labs was acted upon for Resident 1. These failures placed resident 1 at risk for adverse consequences due to receiving an excessive dose of a medication, and lack of laboratory tests to monitor drug levels. Findings: According to the admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses which included kidney transplant and immunodeficiency (a weakened immune system) due to medications. A review of Resident 1 ' s After Visit Summary (a document from the hospital which provided instructions for Resident 1 and included a medication list) dated 9/19/24 indicated, tacrolimus (a medication given to organ transplant recipients designed to prevent organ rejection) 0.5MG capsule .Take 2 capsules (1mg) by mouth every morning AND 3 capsules (1.5mg) every evening . A record review of Resident 1 ' s Order Summary Report indicated, tacrolimus Oral Capsule 5mg Give 3 capsule by mouth in the morning for immunosuppression [lowering the body's ability to fight infection] . and Tacrolimus Oral Capsule 5mg .Give 3 capsule by mouth in the evening for immunosuppression . On 1/2/25 at 11:05 A.M., an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated when Resident 1 was admitted , all medication orders, including the dose, were verified with the primary care physician. After the orders were verified, an admission nurse used the Hospital After Visit Summary to transcribe Resident 1 ' s medications into the facility ' s Electronic Health Record (EHR). The ADON stated Resident 1 ' s tacrolimus order was mistakenly entered into the EHR for 5 mg instead of 0.5 mg. The ADON stated Once the orders are in [the EHR], the pharmacy lets us know if there are any issues . and a Medication Regimen Review (MRR—a review by a pharmacist of all medications a patient is currently using designed to prevent, identify, report and resolve medication-related problems, or other irregularities) is conducted by the pharmacy consultant. The ADON stated the error was not identified, and Resident 1 received the incorrect dose of tacrolimus throughout her stay at the facility. On 1/2/25 at 1:44 PM, a telephone interview was conducted with the Pharmacy Consultant (PC) 1. PC 1 Page 1 of 3 055964 055964 02/04/2025 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated he performed an Interim Medication Regimen Review (MRR) for Resident 1 on 9/20/24. PC 1 stated he did not identify the error in Resident 1 ' s tacrolimus dose. PC 1 stated during the Interim MRR, the After Visit Summary was not available in Resident 1 ' s chart. PC 1 stated the purpose of an Interim MRR was to ensure newly admitted residents ' medications were reviewed. PC 1 stated all future MRR ' s were performed monthly by another Pharmacy Consultant. PC 1 stated , .[The Interim MRR] is not intended to be an all-inclusive review .I ' m looking for things that would most likely to be harmful to [the resident] or to the practitioner . A review of Resident 1 ' s MRR dated 9/22/24 indicated, To comply with CMS regulations which require monitoring of drug-related lab work, please ask the MD if we can obtain an order for the following lab work for monitoring purposes .Tacrolimus . A review of resident ' s EHR did not indicate the laboratory tests were done to measure Resident 1's tacrolimus level per PC 2 ' s recommendations. On 1/13/25, a telephone interview was conducted with Pharmacy Consultant (PC) 2. PC 2 stated the recommendation to obtain a tacrolimus level was not done by the facility. PC 2 stated, .obtaining [tacolimus] levels would have identified an irregularity, yes. PC 2 stated a second recommendation to obtain Resident 1 ' s tacrolimus level was given to the facility on [DATE]. A review of Resident 1 ' s MRR dated 10/25/24 indicated, To comply with CMS regulations which require monitoring of drug-related lab work, please ask the MD if we can obtain an order for the following lab work for monitoring purposes: Lipids, Tacrolimus, HgA1c . A handwritten note under Follow-Through indicated, [Resident 1] D/C [discharged ] home. On 1/21/25 an interview was conducted with the Director of Nursing (DON). The DON stated, I would expect [the pharmacy] to find irregularities with any new admits [medications] .I would expect them to do a thorough review of medications . The DON stated it was important for pharmacy recommendations to be completed by the facility to prevent harm for patients if they receive medications. A review of the facility ' s policy titled Medication Regimen Reviews, revised May 2019, indicated, The MRR involves a thorough review of the resident ' s medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities, for example: a. medications ordered in excessive doses .d. inadequate monitoring for adverse consequences .9. An irregularity .may also include the use of medication without adequate monitoring, in excessive doses, and or in the presence of adverse consequences . 055964 Page 2 of 3 055964 02/04/2025 Friendship Manor Nursing & Rehab Center 902 South Euclid Avenue National City, CA 91950

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 one of three residents reviewed for medications (Resident 1) was free from significant medication errors when the prescribed dose of tacrolimus (a medication given to organ transplant recipients designed to prevent organ rejection) was not given per physician ' s orders. Residents Affected - Few This failure placed Resident 1 at risk for adverse effects and health decline. Findings: During a record review on 1/3/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included kidney transplant and immunodeficiency (the body ' s inability to fight against infection) due to drugs. The admission Record indicated Resident 1 was discharged home on [DATE]. During a record review on 1/3/25, the After Visit Summary (a document from the hospital which provided instructions for Resident 1 including a medication list) dated 9/19/24 indicated, tacrolimus 0.5MG capsule .Take 2 capsules (1mg) by mouth every morning AND 3 capsules (1.5mg) every evening [to equal 2.5 milligrams per day] . During a record review on 1/3/25, Resident 1 ' s Order Summary Report indicated, tacrolimus Oral Capsule 5mg Give 3 capsule by mouth in the morning for immunosuppression (lessen the body ' s ability to fight infection) . and Tacrolimus Oral Capsule 5mg .Give 3 capsule by mouth in the evening for immunosuppression [to equal 25 milligrams per day] . On 1/3/25 an interview was conducted with the Director of Staff Development (DSD). The DSD stated the medication tacrolimus was incorrectly entered into Resident 1 ' s chart as 5mg instead of 0.5mg when she was admitted . As a result, Resident 1 was given a total of 25mg per day, which is a higher amount of the medication than the physician ordered. On 1/3/25, a review of Resident 1 ' s Medication Administration Record indicated Resident 1 received 25mg daily for 29 out of 37 days during her admission. On 2/5/25 at 8:53 A.M., an interview was conducted with the Medical Director (MD). The MD stated it was important for Resident 1 to receive the correct dose of the medication. The MD stated a higher dose of the medication, .potentially could have led to adverse effects, such as infection . The MD stated it was his expectation for staff to administer the correct dose of the medication. A record review was conducted on 2/3/25. The facility ' s policy titled Administering Medications revised 4/19 indicated, Medications are administered in a safe and timely manner, as prescribed . 055964 Page 3 of 3