Health inspection·January 9, 2025

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** Residents Affected - Few Based on observation, interviews, and record reviews, the facility failed to follow its policy and procedure regarding medication error and adverse drug reaction reporting, for one of four sampled residents (Resident 1) when Resident 1 did not receive Pirfenidone (a medication to treat pulmonary fibrosis – a disease that damages the lung tissue, making it difficult to breathe) on December 21, 2024. This failure resulted in Resident 1 not receiving one dose of Pirfenidone and had the potential to adversely affect the health and safety of Resident 1 by causing a decline in lung function (when lung tissues cannot expand enough). Findings: During a review of Resident 1's admission Record (It contains demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with a diagnosis that included acute respiratory failure (is a serious condition that occurs when the body's respiratory system is unable to meet the body's need for oxygen or remove carbon dioxide). During a review of Resident 1's clinical records, the Brief Interview for Mental Status (BIMS- screening tool to identify and monitor cognitive decline), dated November 22, 2024, indicated, Resident 1's score was a 15, which indicated Resident 1 had no mental impairment. During a review of Resident 1's Medication Administration Record (MAR- is the report that serves as a legal record of the drugs administered to a patient at the facility) for the month of December 2024, the MAR indicated Resident 1 was prescribed Pirfenidone 267 mg (milligram-unit of measurement) for interstitial lung disease (ILD - which causes scarring in the lungs, making it difficult to breathe). to be taken three times a day for seven days, starting December 16, 2024, until December 26, 2024. The MAR indicated the 5:00 p.m. dose on December 21, 2024, was not administered. During an interview on December 26, 2024, at 1:32 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, she had disposed of a bottle of the Resident 1's medication Pirfenidone, in the designated medication disposal container after the morning medication administration, believing that the medication had been discontinued. She realized this at approximately 3:00 PM, that same day, December 21, 2024. LVN 1 further stated, as a result, the medication was not administered. During a concurrent interview and record review on December 26, 2024, at 2:48 PM, with the Director of Nursing (DON ), the MAR for the month of December 2024, was reviewed. The DON stated Pirfenidone Page 1 of 2 555379 555379 01/09/2025 Asistencia Villa Healthcare Center 1875 Barton Rd Redlands, CA 92373

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 267 mg scheduled to be given on December 21, 2024, at 5 PM, was not given to Resident 1 because it was not available. The DON further stated LVN 1 mistakenly disposed of all the specific medications believing it was discontinued, as the facility's regular pharmacy did not supply them, [name of the pharmacy] provided the required medication. During a telephone interview on January 6, 2025, at 5:18 PM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated, she was unable to administer the 5:00 PM dose of Pirfenidone medication on December 21, 2024, because the medication was not available. LVN 2 further stated, according to what she heard, the medication was accidentally discarded by another staff member. During a concurrent telephone interview and record review on January 8, 2025, at 11:47 AM with the DON, the facility's policy and procedure (P&P) titled, Medication Error and Adverse Drug Reaction Reporting, dated March 2024. The P&P indicated, Definitions . Medication Error/Discrepancy: An incorrect medication prescribed, dispensed, or administered to a resident; an omission of a vital medication due to a prescribing, dispensing, or administering error; medication administered to an individual with a documented allergy to that medication. The DON stated, the facility staff did not follow the policy. 555379 Page 2 of 2