**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Sixty-four medication errors out of 82 total opportunities contributed to an overall medication error rate of 78 % affecting 17 out of 20 residents observed during medication administration (Resident 1, 2, 3, 4, 6, 8, 14, 15, 16, 18, 22, 25, 26, 35, 38, 44, and 99). The medication errors were as follows: 1. Omitted or late administration of Amiloride HCI (medication to treat high blood pressure) 10 milligram ([mg] unit of measurement) for hypertension ([HTN] high blood pressure), of Finasteride (medication to treat overgrowth of prostate) 5.0 mg for benign prostatic hyperplasia ([BPH] a condition when the prostate [male organ] and surrounding tissue expands), Namenda (medication to treat Alzheimer's [a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) 10 mg for Alzheimer's disease to Resident 1. 2. Omitted or late administration of Acetazolamide (medication to treat glaucoma) 500 mg, Benztropine Mesylate (medication to help body fight infections) 0.5 mg for immunodeficiency (failure of the immune system to protect the body adequately from infection), Risperdal (medication used to treat schizophrenia) 2 mg, Propranolol HCI (medication to treat high blood pressure) 20 mg, Aspirin (medication used to prevent interruption of blood flow to the cells of the brain) 81 mg for prophylaxis (measures designed to preserve health and prevent the spread of disease) of cerebral vascular accident ([CVA] an interruption in the flow of blood to cells in the brain) to Resident 2 . 3. Omitted or late administration of Metformin (medication to treat high blood sugar) 500 mg to Resident 3. 4. Omitted or late administration of Vascepa (medication to treat high cholesterol) 1.0 gm two capsules for hyperlipidemia, Amantadine HCl (medication to treat involuntary, erratic, twisting movements of the face, arms, legs or trunk) 100 mg for dyskinesia (involuntary, erratic, writhing movements of the face, arms, legs or trunk) Lamotrigine (medication used to treat bipolar disorder [a serious mental illness that causes unusual shifts in mood, ranging from extreme highs to lows] and schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions]) 400 mg, Trihexyphenidyl HCL (medication given to treat Extrapyramidal side effects [EPS], commonly referred to as drug-induced movement disorders) 3.0 gm ([gram] unit of measurement) and Flomax (medication to treat overgrowth of prostate [BPH]) 0.4 mg to Resident 4. 5. Omitted or late administration to Resident 6 of Midodrine (for low blood pressure) 5 mg, Keppra ([Levetiracetam] medication to treat seizure [a sudden, uncontrolled burst of electrical activity in the brain] disorder) 5.0 milliliters ([ml] unit of measurement) of 100 mg/ml for seizure disorder, Gabapentin (medication used to treat nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) 300 mg for neuropathy (a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) to Resident 6. 6. Omitted or late administration of Symbicort inhalation aerosol (medication used to treat [{Asthma} a condition when airways in the lungs become narrowed and swollen, making it difficult to breathe]) 160- 4.5 mg one puff, Norvasc (medication used to treat hypertension) 10 mg HTN, Eliquis (medication to treat damaged tissues in the brain due to a loss of oxygen to the area) 5 mg, Metoprolol Tartrate (medication to treat HTN) 25 mg for HTN, and Losartan Potassium (medication to treat HTN) 25 mg for HTN to Resident 8. 7. Omitted or late administration of Zyprexa ([Olanzapine] medication given to treat hallucinations in mental disorder) 7.5 mg tablet for auditory hallucinations (hearing voices or noises that do not exist in reality) related to schizophrenia and Metformin HCL 500 mg tablet for DM to Resident 14. 8. Omitted or late administration to Resident 15 of Cogentin (medication given to treat EPS) 1.0 mg for EPS, Risperdal (medication to treat schizophrenia)1.0 mg, Metformin HCL 850 mg for diabetes mellitus ([DM] a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel), Lactulose (medication used to treat elevated ammonia levels[high ammonia levels can cause permanent brain damage, coma, and even death]) 15 ml of 10 gm/15 ml for elevated ammonia levels, and Admelog Solution ([Insulin Lispro] medication used to treat elevated blood sugar) 100 units/ml subcutaneously ([SQ] beneath, or under, all the layers of the skin) to Resident 15. 9. Omitted or late administration of Cogentin 1.0 mg for EPS, Amlodipine Besylate (medication used to treat HTN) 10 mg for HTN, Aspirin 81 mg for CVA prophylaxis, Levetiracetam 10 ml of 500 mg/5 ml for epilepsy (a recurrent seizures, which are brief episodes of involuntary movement that may involve a part of the body or the entire body), Topiramate (medication used to treat seizures) 100 mg for seizure, and Haloperidol (a medication to treat schizophrenia) 1.0 mg for schizophrenia to Resident 16. 10. Omitted or late administration of Fluoxetine HCL (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) 10 mg and Levetiracetam 5 ml of 100mg/ml for convulsions to Resident 18. 11. Omitted or late administration of Carvedilol (medication used to treat high blood pressure) 6.25 mg for HTN, Duloxetine HCl (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) 60 mg for major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Amlodipine Besylate 10 mg for HTN, and Aspirin 81 mg for CVA prophylaxis to Resident 22. 12. Omitted or late administration of Amlodipine Besylate 10 mg for HTN and Benazepril HCl (medication used to treat high blood pressure) 40 mg for HTN to Resident 25. 13. Omitted of late administration of Duloxetine HCl 40 mg low mood and anxiety (a feeling of worry, nervousness, or unease, typically about an imminent event or something with an uncertain outcome), Baclofen (medication used to treat muscle spasms [an involuntary and abnormal muscular contraction]) 10 mg for muscle spasms, Amlodipine Besylate 5 mg tablet for HTN, Gabapentin 400 mg for neuropathy, and Keppra 500 mg for seizure to Resident 26. 14. Omitted or late administration of Lasix (diuretic) 60 mg for heart failure (condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), Gabapentin 600 mg, Metformin HCl 1000 mg for diabetes mellitus (DM), Carvedilol 6.25 mg for HTN, Benazepril HCL 40 mg HTN, Clonidine (medication used to treat high blood pressure) 0.2 mg for HTN, and Empagliflozin (medication used to treat high blood sugars) 10 mg for DM to Resident 26. 15. Omitted or late administration of Norvasc 5 mg for HTN, Seroquel (medication used for the treatment of schizophrenia) 37.5 mg for bipolar disorder, and Aspirin 81 mg for CVA prophylaxis to Resident 38. 16. Omitted or late administration of Topamax (medication used to treat seizure) 100 mg for seizure, Lacosamide (medication used to treat seizures) 100 mg for seizure, Keppra 750 mg for seizure, Lisinopril (medication used to treat abnormally high blood pressure) 20 mg for HTN, Cymbalta (medication used to treat a mood disorder that causes a persistent feeling of sadness and loss of interest) delayed release capsule 30 mg, Sinemet (medication used to treat Parkinson's disease [a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves]) 10 mg of 10-100 mg for Parkinson's disease, Aspirin 81 mg for CVA prophylaxis, Cenobamate (medication given to treat seizures) 50 mg for seizure, and Baclofen 10 mg for muscle spasm to Resident 44. 17. Omitted or late administration of Morphine Sulfate (narcotic medication used to treat pain) 15 mg for pain to Resident 99. 18. Follow their policy and procedure titled Administering Medications, which indicated medications are administered in accordance with prescriber orders, including required time frame within one before or after prescribed/scheduled time. This deficient practice of failing to administer medications in accordance with the physician's orders at the scheduled administration time increased the risk that Resident 1, 2, 3, 4, 6, 8, 14, 15, 16, 18, 22, 25, 26, 35, 38, 44, and 99 may have experienced serious medical complications such as stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts) or complications related to poor blood sugar control including hyperglycemia (an excess of sugar in the bloodstream), diabetic coma (a life-threatening disorder that causes unconsciousness), uncontrolled seizure, worsening of depression, anxiety, and schizophrenia with associated complications including death. On 2/3/2024 at 7:01 p.m., an Immediate Jeopardy (situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) situation was identified and declared in the presence of Director of Nursing (DON) and Administrator (Admin) due to the facility's failure to ensure that its medication error rate was less than 5%. The medication error rate was 75.86 %. On 2/4/2024 at 7:15 p.m., the facility provided the California Department of Public Health (CDPH) with an Immediate Jeopardy Removal Plan (IJRP) containing the following summarized actions: 1. On 2/3/24, the DON immediately initiated incident reports by way of the Risk Management section of the facilities Electronic Medical Records system as well as notifying the attending physician for the 17 residents affected by the deficient practice. Initiated 2/4/24 care plans are being updated with additional monitoring added to resident EMAR's in order to ensure they are not experiencing any adverse reactions that could have been cause by the delay of the medication administration described in the CMS-2567, F759. Also, on 2/4/24 11 alert orientated residents and 6 responsible parties will being notified that they received their medication late by the Director of Nursing to ensure they are fully aware of medication error and risk involved. 2. Effective immediately on 2/4/24, the Medical Records Director initiated a clinical audit facility wide of resident Medication Administration Records to ensure they are accurate, complete, and timely. The results of this audit will be shared with the Director of Nurses and Medical Director for recommendations and/or possible immediate corrective actions. 3. Commencing on 2/3/24 the Director of Nursing Service initiated in-service training of the licensed nursing staff as they are scheduled on the policies of Administering Medications, Documentation of Medication Administration, Adverse Consequences & Medication Errors, Medication Errors, as well as Attendance and Punctuality in order to ensure that all licensed nursing staff I fully aware of these important and required policy and procedure changes to immediately follow. This in-service training will include a quiz on the information provided with a special focus on medication administration timeliness and attendance. Staff who are on vacation or who cannot attend the in-service training will be notified by way of email of the Immediate Jeopardy and the policy changes and standards that must be adhered too. 4. Effective immediately on 2/3/24 the Director of Nursing services will review the attendance and punctuality of the facilities licensed nursing staff with the facility Administrator for possible recommendation for resolution. Also, the licensed nursing staff will be required to contact the facility to notify the charge nurse on duty if they are going to be more than 15 minutes late. If no arrival or contact occurs from oncoming scheduled licensed nurse staff the charge nurse on duty will be required to contact the Director of Nursing immediately. Immediate changes to the facility Attendance and Punctuality Policy now requires all employees to submit vacation and time off request 30 days in advance to ensure that there is ample time to schedule coverage for the time off being requested. Another immediate change in the Attendance and Punctuality Policy is if employees will not be able to report for their assigned shift, they must notify their supervisor and the facility within (2 hours for CNA; 4 hours for Licensed Nurse), of the start of their shift. Failure to follow the Attendance Policy may result in further disciplinary action up to and including possible termination of employment. 5. Effective 2/4/24 the facility will now require a charge nurse back up that will administer medication in the event that the scheduled nurse is late or does not report for their assigned shift. The following licensed nurse positions will substitute for the medication administration pass in the following order: 1. Desk Nurse, 2. Director of Staff Development, 3. Infection Prevention Nurse, 4. Director of Nursing and/or 5. Nursing Registry. 6. Effective 2/4/24 the Director of Nursing will ensure that the Licensed Nurses' schedule will be completed at a minimum 45 days forward by the 15th of each month to ensure that there is a stable staffing plan that is well prepared in advance. Thus, avoiding and/or reducing the likely hood of reoccurrence of a negative outcome with medication administration. 7. Effective 2/4/24 the Director of Nursing will spot check the performance of the license nurses by observing the medication administration to ensure they are efficient and timely without delay. Negative finding will be immediately addressed when they occur and then brought forward to the QA/QAPI committee for review and root cause analysis. On 2/4/2024 at 7:31 p.m., while onsite, after verification through observation, interview, and record review the facility's implementation of the IJ immediate corrective actions, the Immediate Jeopardy was removed, in the presence of the Administrator and DON. Findings: 1. During a review of Resident 1's Face Sheet (admission record), dated 2/4/2024, the face sheet indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including Alzheimer's Disease, HTN, and BPH. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/11/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 1 had medically complex conditions and was receiving antipsychotic and antidepressant medications. During a review of Resident 1's physician's order dated 6/30/2023, the physician's order indicated an order for Amiloride HCI 5.0 mg to administer two tablets (10 mg) for hypertension, the order dated 3/19/2019 for Finasteride (medication to treat overgrowth of prostate) 5.0 mg give one tablet daily for BPH, and the order for Namenda 10 mg one tablet daily for Alzheimer's disease. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., the licensed vocational nurse (LVN 2) did not administer to Resident 1 Amiloride HCI 10 mg, Finasteride 5 mg, and Namenda 10 mg at 7:30 a.m., as scheduled. During a review of Resident 1's Medication Administration Record (MAR) dated 2/3/2024, the MAR indicated medication Amiloride HCI 10 mg was administered on the same day 2/3/24 at 12:09 p.m., instead as scheduled at 7:30 a.m., and Finasteride 5 mg and Amenda 10 mg were administered on 2/3/24 at 12:10 a.m., which was approximately 4.0 hours and 40 minutes later than scheduled time. 2. During a review of Resident 2's Face Sheet (admission Record), dated 2/4/2024, the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnosis including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interaction), immunodeficiency, glaucomatous flecks (subcapsular [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve]) both eyes, and HTN. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by others and his vision was severely impaired. The MDS Section N0415 High-Risk Drug Classes indicated Resident 2 had medically complex conditions and was receiving antipsychotic and antiplatelet medication (a group of medicines that stop blood cells (called platelets) from sticking together and forming a blood clot). During a review of Resident 2's physician's order dated 3/12/2019, the physician's order indicated an order for Acetazolamide 500 mg by mouth twice a day for glaucoma, the order dated 8/4/2021 for Benztropine Mesylate 0.5 mg tablet twice a day for immunodeficiency, the order dated 10/24/2022 for Risperdal 2 mg by mouth in the morning for mood swings related to schizophrenia, the order date 2/4/2021 for Propranolol HCI 20 mg tablet twice a day for HTN, and the order dated 7/31/2023 for Aspirin (medication used to prevent interruption of blood flow to the cells of the brain) 81 mg tablet by mouth once a day in the morning for prophylaxis (measures designed to preserve health and prevent the spread of disease) of cerebral vascular accident ([CVA] an interruption in the flow of blood to cells in the brain). During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering to Resident 2 Acetazolamide 500 mg one tablet, Benztropine Mesylate 0.5 mg one tablet and Risperdal 2.0 mg two tablets as scheduled at 7:30 a.m. During a review of Resident 2's MAR dated 2/3/2024, the MAR indicated medication Acetazolamide 500 mg one tablet, Benztropine Mesylate 0.5 mg one tablet and Risperdal 2.0 mg two tablets were administered on 2/3/24 at 12:03 p.m , which was approximately 4.0 hours and 30 minutes later than scheduled time. 3. During a review of Resident 3's Face Sheet (admission Record), dated 2/4/2024, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus (abnormal blood sugar) and muscle weakness. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 usually was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 3 had medically complex conditions and was receiving hypoglycemic medication (a medication to lower blood sugar level). range). During a review of Resident 3's physician's order dated 6/30/2023, the physician's order indicated the order for Metformin (medication to treat high blood sugar) 500 mg one tablet twice a day for diabetes. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Metformin 500 mg one tablet to Resident 3 for diabetes as scheduled at 7:30 a.m. During a review of Resident 3's MAR dated 2/3/2024, the MAR indicated medication Metformin 500 mg one tablet was administered on 2/3/24 at 11:11 a.m., which was approximately 3.0 hours and 40 minutes later than scheduled time. 4. During a review of Resident 4's Face Sheet (admission Record), dated 2/4/2024, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with diagnosis including hyperlipidemia (abnormally high concentration of fat particles [lipids] in the blood), schizoaffective disorder (a disorder that affects a person's ability to think, feel, and behave clearly) and unspecified abnormal involuntary movements (occurs when you move your body in an uncontrollable and unintended way). During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4 was able to understand and usually was understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 4 had medically complex conditions and was receiving antipsychotic medication (used to treat symptoms of psychosis [when a person loses contact with reality including seeing or hearing things that others cannot see or hear (hallucinations) and believing things that are not actually true (delusions)]). During a review of Resident 4's physician's order dated 2/21/2023, the physician's order indicated an order for Vascepa 1.0 gm two capsules by mouth twice a day with food for hyperlipidemia, the order dated 5/26/2015 for Amantadine HCl 100 mg one tablet by mouth daily for dyskinesia related to unspecified abnormal involuntary movements, order dated 9/8/2021 for Lamotrigine 400 mg daily for mood lability (unpredictable, uncontrollable, and rapid shifts in emotions) and psychosis, the order dated 3/21/2023 for Trihexyphenidyl HCL 3.0 gm twice a day for EPS, and the order date 8/22/2023 Flomax 0.4 mg one capsule daily. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Vascepa 1.0 gm two capsules, Amantadine HCl 100 mg one tablet, Lamotrigine 400 mg, Trihexyphenidyl HCL 3.0 gm, and Flomax 0.4 mg one capsule to Resident 4 as scheduled at 7:30 a.m. During a review of Resident 4's MAR dated 2/3/2024, the MAR indicated medication Vascepa 1.0 gm two capsules medication, Amantadine HCl 100 mg one tablet, Lamotrigine 400 mg, Trihexyphenidyl HCL 3.0 gm, and Flomax 0.4 mg one capsule were administered on 2/3/24 at 11:48 a.m., which was approximately 4.0 hours and 30 minutes later than scheduled time. 5. During a review of Resident 6's Face Sheet (admission record), dated 2/4/2024, the Face Sheet indicated Resident 6 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including epilepsy (brain condition that causes recurring seizures), and orthostatic hypotension (low blood pressure that happens when standing after sitting or lying down.) During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 was able to understand and be understood by others. The MDS indicated Resident 6 had debility (state of general weakness that may be a result or an outcome of one or more medical conditions) and cardiorespiratory (related to heart and lungs) condition. The MDS Section N0415 High-Risk Drug Classes indicated Resident 6 was receiving antidepressants (medication for sadness.) During a review of Resident 6's physician's order dated 8/31/2023, the physician's order indicated an order for Midodrine 5 mg one tablet by mouth three times a day, order dated 3/31/2023 for Keppra 100 mg/ml) to administer 5.0 ml by mouth twice a day for seizure disorder, an order for Gabapentin 300 mg by mouth twice a day for neuropathy (weakness, numbness, or pain from nerve damage). During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Midodrine 5 mg tablet, Keppra 500 mg Gabapentin 300 mg to Resident 6 as scheduled at 7:30 a.m. During a review of Resident 6's MAR dated 2/3/2024, the MAR indicated medication Midodrine 5 mg tablet, Keppra 500 mg and Gabapentin 300 mg were administered on 2/3/24 at 11:07 a.m., which was approximately 3.0 hours and 30 minutes later than scheduled time. 6. During a review of Resident 8's Face Sheet (admission Record), dated 2/4/2024, the Face Sheet indicated Resident 8 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including transient ischemic attack ([TIA] occurs when the blood supply to part of the brain is briefly interrupted), and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and HTN. During a review of Resident 8's MDS, dated [DATE], the MDS indicated Resident 8 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 8 had a stroke and was receiving antipsychotics and anticoagulant medication. During a review of Resident 8's physician's order dated 8/31/2023, the physician's order indicated the order for Symbicort inhalation aerosol (medication used to treat [{Asthma} a condition when airways in the lungs become narrowed and swollen, making it difficult to breathe]) 160- 4.5 mg one puff to inhale orally twice a day for asthma, the order dated 10/17/2022 for Norvasc 10 mg once a day for HTN, the order date 10/17/2022 for Eliquis 5 mg one tablet by mouth twice a day for cerebral infarction, the order dated 9/24/2023 for Metoprolol Tartrate 25 mg one tablet by mouth twice a day for HTN, and the order dated 12/7/2021 for Losartan Potassium 25 mg by mouth daily for HTN. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administering Symbicort aerosol 160- 4.5 mg inhaler, Norvasc 10 mg, Eliquis 5 mg, Metoprolol Tartrate 25 mg and Losartan Potassium 25 mg to Resident 8 as scheduled at 7:30 a.m. During a review of Resident 8's MAR dated 2/3/2024, the MAR indicated medications Symbicort inhalation aerosol 160- 4.5 mg, Norvasc 10 mg, Eliquis 5 mg, Metoprolol Tartrate 25 mg and Losartan Potassium 25 mg were administered on 2/3/24 at 11:48 a.m., which was approximately 4.0 hours and 30 minutes later than scheduled time. 7. During a review of Resident 14's Face Sheet (admission Record), dated 2/4/2024, the Face Sheet indicated Resident 14 was admitted to the facility on [DATE], with diagnosis including schizophrenia, type 2 diabetes mellitus (DM), and HTN. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had cognitive (thinking, reasoning, or remembering) impairment for daily decision making. The MDS indicated Resident 14 was dependent with toileting hygiene, bathing, and dressing. The MDS Section N0415 High-Risk Drug Classes indicated Resident 14 was taking antipsychotic, antidepressant, and hypoglycemic medication. During a review of Resident 14's physician's order dated 6/11/2020, the physician's order indicated the order for Zyprexa ([Olanzapine] medication given to treat hallucinations in mental disorder) 7.5 mg tablet by mouth in the morning daily for auditory hallucinations (hearing voices or noises that don't exist in reality) related to schizophrenia. During a review of Resident 14's physician's order dated 6/24/2020, the physician's order indicated the order for Metformin HCL 500 mg tablet by mouth two times a day for DM. During a review of Resident 14's MAR, dated 2/3/2024, the MAR indicated Resident 14's Metformin 500 mg and Zyprexa 10 mg, scheduled for administration at 8 a.m., were administered on 2/3/2024 at 10:54 a.m. approximately 3 hours later than scheduled time. 8. During a review of Resident 15's Face Sheet (admission Record), dated 2/4/2024, the Face Sheet indicated Resident 15 was admitted to the facility on [DATE] with diagnosis including encephalopathy (disease of the brain where functioning is affected by a condition or toxins), type 2 diabetes mellitus (DM) and paranoid schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly). During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 15 had a medically complex condition and was receiving hypoglycemic medication. During a review of Resident 15's physician's order dated 1/6/2022, the physician's order indicated the order for Cogentin 1.0 mg tablet by mouth twice a day for EPS due to Risperdal usage related to schizophrenia m/b delusion as evidence by hallucination, the order dated 2/9/2023 for Risperdal 1.0 mg tablet by mouth twice a day for paranoid schizophrenia, the order dated 10/26/2022 for Metformin HCL 850 mg by mouth twice a day for DM, the order dated 7/26/2021 for Lactulose 10 gm/15 ml to give 15 ml by mouth daily for elevated ammonia levels, and the order dated 10/3/2021 for Admelog Solution 100 units/ml inject SQ) before meals and at bedtime for diabetes per sliding scale as follows: a. For blood sugar level 151 to 200 - administer two units. b. For blood sugar level 201 to 250 - administer four units. c. For blood sugar level 251 to 300 - administer six units. d. For blood sugar level 301 to 350 -administer eight units. e. For blood sugar level 351 to 400 - administer 10 units. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administer Cogentin 1.0 mg and Risperdal 1.0 mg, did not administer Insulin Lispro per sliding scale before breakfast as scheduled at 7:30 a.m., did not administer Metformin 850 mg as scheduled at 7:30 a.m., and Lactulose 10 gm to Resident 15 as scheduled at 8 a.m. During a review of Resident 15's MAR dated 2/3/2024, the MAR indicated medication Cogentin 1.0 mg, was administered on 2/3/2024 at 11:24 a.m., Risperdal 1.0 mg was administered at 11:25 a.m., Admelog Solution (Insulin Lispro) per sliding scale was administered at 11:27 a.m., and not before breakfast at 8 a.m., Metformin 850 mg was administered and Lactulose 10 mg were administer at 11:24 a.m., which was approximately 4.0 hours later than medication administration scheduled time. 9. During a review of Resident 16's Face Sheet (admission record), dated 2/4/2024, the Face Sheet indicated Resident 16 was admitted to the facility on [DATE] with diagnosis including epilepsy, schizophrenia, and HTN. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16 was able to understand and be understood by others. The MDS Section N0415 High-Risk Drug Classes indicated Resident 16 had a medically complex condition and was receiving antipsychotic, hypoglycemic, and antiplatelet medication. During a review of Resident 16's physician's order dated 6/28/2021, the physician's order indicated the order for Cogentin 1.0 mg tablet by mouth twice a day for EPS due to Haloperidol (medication used to treat nervous, emotional, and mental disorders) use for schizophrenia, the order dated 6/30/2021 for Amlodipine Besylate 10 mg one tablet by mouth once a day for HTN, the order dated 6/30/2021 for Aspirin 81 mg tablet by mouth once day for CVA prophylaxis, the order dated 10/3/2022 for Levetiracetam (used to treat epilepsy [burst of electrical activity in the brain that temporarily affect how it works]) 500 mg/5 ml to give 10 ml by mouth for epilepsy, the order dated 10/3/2022 for Topiramate 100 mg tablet by mouth twice a day for seizure, and the order dated 3/15/2023 for Haloperidol 1.0 mg tablet by mouth twice a day for schizophrenia. During an observation of the medication pass, on 2/3/2024 starting at 10:02 a.m., LVN 2 did not administer Cogentin 1.0 mg, Amlodipine Besylate 10 mg, Aspirin 81 mg, Levetiracetam 1000 mg, Topiramate, and Haloperidol 1 mg to Resident 16 as scheduled at 7:30 a.m. During a review of Resident 16's MAR dated 2/3/2024, the MAR indicated medication Amlodipine Besylate was administered at 11:20 a.m., Cogentin 1.0 mg, Aspirin 81 mg, Haloperidol 1.0 mg, and Levetiracetam 1000 mg were administered at 11:21 a.m., Topiramate 100 mg was administered at 11:22 a.m., which was approximately 4.0 hours later than medication administration scheduled time. 10. During a review of Resident 18's Face Sheet (admission Record), dated 2/4/2024, the Face Sheet indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including unspecified convulsions (rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement), and major depressive disorder (a mood disorder