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 Page 1 of 2 555379 555379 07/07/2025 Asistencia Villa Healthcare Center 1875 Barton Rd Redlands, CA 92373

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assignment before administering medications. He further stated LVN 1 approached him that night claiming he also gave the same medication to Resident 1. The doctor was called, and Resident 1 was monitored and remained stable. Additionally, LVN 2 confirmed the Metoprolol was in a bubble pack (type of packaging) in his cart, and noted there was also the same medication, intended for Resident 1, in LVN 1's cart. However, they did not know how this situation occurred. During a review of the Medication Administration Record (MAR), dated May 2025, for Resident 1, the MAR indicated that Resident 1 received Metoprolol Tartrate 100 mg on May 23, 2025, at 9:00 PM signed by LVN 2. MAR did not 3indicate that the administration of the same medication, which is Metoprolol Tartrate 100 mg, which LVN 1 reported administering approximately thirty (30) minutes earlier on May 23, 2025, after LVN 2 accidentally administer the same medication was documented. During a concurrent interview and record review on June 23, 2025, at 1:56 PM, with the Administrator (Admin), the facility's policy and procedure (P&P) titled, Documentation of Administration of Medication, dated November 2022 was reviewed. The P&P indicated, .Administration of medication is documented immediately after it is given . The Admin stated that policy was not followed. During a concurrent interview and record review on June 23, 2025, at 2:02 PM, with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Documentation of Administration of Medication, dated November 2022 was reviewed. The P&P indicated, .Administration of medication is documented immediately after it is given . The DON stated the staff must verify the orders and adhere to the five rights of medication administration. Additionally, proper documentation is required. When asked whether this P&P was followed, the DON stated, It was not followed. 555379 Page 2 of 2