Health inspection·February 14, 2024

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 licensed nurses administered the prescribed dose of Clozaril (an Antipsychotic medication [medications that are used for some types of mental distress or disorder] to treat schizophrenia [a serious mental illness that affects how a person thinks, feels, and behaves]) 200 milligrams (mg-unit of measure) to one of nine sampled residents (Resident 1) from 11/23/2023 to 1/29/2024. Resident 1 was administered a total of 31 incorrect (higher than prescribed) doses of Clozaril. Residents Affected - Some The deficient practice of failing to administer medications in accordance with physician's orders placed Resident 1 at risk for serious health complications as a result of being administered a higher dose of Clozaril than prescribed. Findings: A review of Resident 1 ' s Face Sheet (admission record) indicated the resident was admitted to the facility on [DATE] with diagnoses that included schizophrenia. A review of Resident 1' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/28 /23 indicated Resident 1 had moderately impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 1 required supervision with eating and oral hygiene. A review of Resident 1 ' s Physician ' s Orders indicated the following: 1. Clozaril 225 mg by mouth twice a day for schizophrenia manifested by constant talking, ordered 1/19/2020 and discontinued 11/22/2023. 2. Clozaril 200 mg by mouth twice a day for schizophrenia manifested by constant talking, with order date of 11/22/2023. A review of Resident 1 ' s Clozaril medication bubble pack (a small package enclosing the medication in transparent dome-shaped plastic on a flat cardboard backing that also includes a count of the medications remaining and the total amount of medications administered) indicated the following: 1. Clozapine 200 mg tablet, with a label: morning, with 18 tablets intact of a package of 31 tablets, delivery date 1/05/2024. 2. Clozapine 25 mg tablet, with a label: morning, with 16 tablets intact of a package of 31 Page 1 of 4 555045 555045 02/14/2024 The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040

F 0760 tablets, delivery date 1/05/2024. Level of Harm - Minimal harm or potential for actual harm 3. Clozapine 200 mg tablet, with a label: evening, with 17 tablets intact of a package of 31 tablets, delivery date 1/05/2024. Residents Affected - Some 4. Clozapine 25 mg tablet, with a label: morning, with 18 tablets intact of a package of 31 tablets, delivery date 1/05/2024. A review of Resident 1 ' s Care Plan for Antipsychotic Medication, last reviewed 12/23/2023, indicated a goal that Resident 1 will interact peacefully in social situations for 90 days. The care plan indicated an intervention to administer medications as ordered. During a concurrent interview and record review on 1/29/2024, at 1:00 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed Resident 1 ' s Medication Administration Record (MAR- a record of all medications taken by a resident on a day-to-day basis) for 11/2023, 12/2023, and 1/2024. LVN 1 stated that on the following dates, LVN 1 administered 225mgs of Clozapine to Resident 1 instead of the prescribed dose of 200 mgs of Clozapine: 1. 11/24/2023 9 a.m. dose 2. 11/25/2023 9 a.m. dose 3. 11/30/2023 9 a.m. dose 4. 12/09/2023 9 a.m. dose 5. 12/15/2023 9 a.m. dose 6. 12/21/2023 9 a.m. dose 7. 12/22/2023 9 a.m. dose 8. 12/23/2023 9 a.m. dose 9. 12/28/2023 9 a.m. dose 10. 12/29/2023 9 a.m. dose 11. 1/03/2024 9 a.m. dose 12. 1/04/2024 9 a.m. dose 13. 1/06/2024 9 a.m. dose 14. 1/11/2024 9 a.m. dose 15. 1/13/2024 9 a.m. dose 16. 1/15/2024 9 a.m. dose 555045 Page 2 of 4 555045 02/14/2024 The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040

F 0760 17. 1/18/2024 9 a.m. dose Level of Harm - Minimal harm or potential for actual harm 18. 1/19/2024 9 a.m. dose 19. 1/19/2024 5 p.m. dose Residents Affected - Some 20. 1/20/2024 9 a.m. dose 21. 1/21/2024 9 a.m. dose 22. 1/22/2024 9 a.m. dose LVN 1 stated she should have followed Resident 1 ' s physician order of Clozaril 200mg, but mistakenly administered Clozaril 225mg to Resident 1. LVN 1 stated it was important to follow the physician ' s order so that Resident 1 would not receive a higher than intended dose of the medication. LVN 1 stated Resident 1 could have been at risk for sedation (the state of being relaxed or sleepy because of a drug) and constipation (a problem with passing stool) due to receiving a higher than prescribed dose of Clozaril. During a concurrent interview and record review with Licensed Vocational Nurse 2 (LVN 2) on 1/29/2024 at 1:11 p.m., LVN 2 reviewed Resident 1 ' s MAR for 11/2023, 12/2023, and 1/2024. LVN 2 stated that on the following dates, LVN 2 administered 225 mgs of Clozapine to Resident 1 instead of the prescribed dose of 200 mgs of Clozapine: 1. 11/26/2023 9 a.m. dose 2. 11/27/2023 9 a.m. dose 3. 11/28/2023 9 a.m. dose 4. 12/03/2023 9 a.m. dose 5. 12/04/2023 9 a.m. dose 6. 12/05/2023 9 a.m. dose 7. 12/10/2023 9 a.m. dose 8. 12/30/2023 9 a.m. dose 9. 12/31/2023 9 a.m. dose LVN 2 stated she should have followed Resident 1 ' s physician order of Clozaril 200 mg, but mistakenly administered Clozaril 225 mg to Resident 1. LVN 2 stated it was important to follow the physician ' s order so that Resident 1 would not receive a higher than intended dose of the medication. LVN 2 stated that Resident 1 could have been at risk for becoming lethargic (lack of energy) or be at risk for falls. During a concurrent interview and record review with the Director of Nursing (DON) on 2/14/2024 at 555045 Page 3 of 4 555045 02/14/2024 The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040

F 0760 Level of Harm - Minimal harm or potential for actual harm 3:15 p.m., the DON read the facility ' s policy and procedure titled, Specific Medication Administration Procedures General Procedures to Follow For All Medications last reviewed on 10/11/2023. The policy and procedure indicated the licensed nurse is to read the medication label three times before pouring (giving). The DON stated it was implied in the policy that the licensed nurse will check the medication label with the physician ' s order to ensure the right medication dose is given to the resident. Residents Affected - Some 555045 Page 4 of 4