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 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555045 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555045 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Hills Healthcare Center 10158 Sunland Blvd Sunland, CA 91040 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)