Health inspection·July 7, 2025

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. 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 blood pressure medication was not administered in duplicated dose for one of three sampled residents (Resident 1). Residents Affected - Few This failure had the potential for Resident 1 to receive an excessive dosage of the medication which could jeopardize her health and safety. Findings: During a review of Resident 1's admission record (information about the patient's personal details, reason for admission, and medical history), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included cardiac arrest (the heart suddenly and unexpectedly stops pumping blood to the brain and other vital organs). During a review of the facility provided document titled Progress Notes, for Resident 1, dated May 24, 2025, at 2:18 AM, the Progress Notes indicated an entry from Licensed Vocational Nurse (LVN 1) stating: Double dose given, MD [Doctor of Medicine] notified, and receive the order for continually monitor for Hypotensive [low blood pressure]. During a review of the physician's order for Resident 1, dated April 28, 2025, the physician's order indicated Metoprolol Tartrate Oral Tablet 100 mg (Metoprolol Tartrate) Give 100 mg via G-Tube [ Gastrostomy tube is a tube inserted into the stomach, providing a pathway for nutrition, fluids, and medications.) every 12 hours for HTN [hypertension-high blood pressure] Hold for SBP [systolic blood pressure- is the top number in a blood pressure reading, representing the pressure in arteries when the heart beats]. During a telephone interview on June 23, 2025, at 12:39 PM, LVN 1 stated Resident 1 was given Metoprolol (medication to lower blood pressure) twice - first by him and then by another Licensed Vocational Nurse (LVN 2). LVN 1 stated he initially administered the medication at approximately 8:00 PM but was interrupted by another resident before he could document it. Upon returning to document the medication, he found that LVN 2 had already recorded the administration, as he saw LVN 2 had just left the room. When LVN 1 questioned LVN 2 about this, LVN 2 admitted to giving the medication as well, mistakenly thinking that Resident 1 was assigned to him. During an interview with LVN 2 on July 1, 2025, at 7:25 AM, LVN 2 stated he had been assigned to care for Resident 1 for the two nights leading up to the incident. LVN 2 stated he did not check their (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 2 Event ID: 555379 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 555379 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Asistencia Villa Healthcare Center 1875 Barton Rd Redlands, CA 92373 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)