**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 11 of 20 sampled residents (Resident 1, 8, 10, 11, 32, 37, 50, 54, 66, 95, and 99), were free of significant medication error. The facility failed to: -Ensure Resident 50 was administered Eliquis (apixaban, an anticoagulant, a blood thinner), Norvasc (amlodipine, a medication used to treat high blood pressure), and aspirin for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), in accordance with the physician's orders for eleven days during February 2025. -Ensure Residents 10, 54, 95 and 99 were administered Eliquis in accordance with physician's orders and facility's policy and procedures titled, Medication Administration - General Guidelines to minimize the risk of adverse consequences (an undesired effect of a drug) including an increased risk of bleeding. -Ensure Resident 1 was administered Depakote (valproic acid, a medication used to control seizures [a sudden, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movement, sensation, or awareness]) on 2/20, 2/22, 2/23, and 2/25/2025 at 9 a.m., and 1 p.m., as ordered and not within 39 minutes to less than two hours of the next scheduled dose. -Ensure Resident 37 was administered Keppra (levetiracetam a medication used to control seizures) on 2/20, 2/22, 2/23, 2/24, and 2/25/2025 at 9 a.m., and 5 p.m. daily as ordered. -Ensure Residents 8, 11, 32 and 66 were administered medications in accordance with physician orders and facility's policy and procedures titled, Medication Administration - General Guidelines to minimize the risk of adverse consequences which could lead to a deterioration in the resident's condition, hospitalization, harm, or death. These deficient practices resulted in: -Residents 10, 50, 54, 95 and 99 were at increased risk of bleeding, including serious bleeding that can be fatal and increased risk of uncontrolled blood pressure, that could lead to stroke, heart attack, hospitalization, or death -Residents 1 and 37 was placed at high risk for hepatotoxicity (liver toxicity, a condition that occurs when the liver is damaged by harmful substances, such as medications, toxins, or chemicals, which can lead to impaired liver function and, in severe cases, liver failure). -Residents 8, 11, 32, and 66 were placed at risk for uncontrolled blood glucose (a type of sugar) levels. On 2/26/2025 at 4:42 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the Administrator (ADM) and Director of Nursing (DON), regarding the facility's failure to identify and ensure Resident 1, 8, 10, 11, 32, 37, 50, 54, 66, 95, and 99, who were at increased risk of bleeding, toxicity or hyperglycemia (increased blood sugar) were free of significant medication error and received necessary care and services in accordance with professional standards of practice. On 2/27/2025 at 4:18 PM, while onsite at the facility, the IJ was removed in the presence of the ADM and DON, after the ADM submitted an acceptable Removal Plan (interventions and implementation to correct the deficient practices) which was verified and confirmed through observation, interview, and record review. The acceptable removal plan was as follows: The Licensed Nurse completed change in condition assessments on 2/26/25 and reported the medication errors for each resident effected with the related medications. The residents would be monitored every shift for adverse reactions. Effected residents were monitored by the DON. Licensed Nurses would be re-educated by the DON before their next Med Pass or on or before 3/15/25 on the standard of practice and facility policy and procedure for administering medications and in accordance with the physician's ordered time to reduce the risk of medication error, serious injury, harm and or death. The DON evaluated the resident medication administration assignments, including evaluation of residents on antiseizure, anticoagulants, hypertensive and anticonvulsant medications, including gastrostomy tubes, dialysis, blood pressure parameter checks, diabetics with insulin administration, controlled pain medications and seizure protocol on 2/26/25. The DON contacted the pharmacy consultant and requested an additional medication cart on 2/26/25, which was verified. The cart would be delivered on 2/26/25. The DON redistributed the resident assignment to ensure the load over four medication carts on 2/26/25. The Interdisciplinary Team met on 2/26/25 and developed and implemented a plan of care to closely monitor effected residents for adverse effects related to receiving medications at the wrong time resulting in a medication error on 2/25/25. The Medical Records staff generated an audit of all in house residents medication administration records including the time of administration for all shifts, identifying any residents who were effected by the medication error. A copy of the audit was provided to the DON for review on 2/27/25. All licensed nurses in the oncoming shifts were prioritized with re-education with the objective to achieve 100% of the licensed nurses before the start of their shift beginning 2/27/25. The Director of Staff Development / designee would complete a medication pass observation skill competency with LVN 1 and 2 prior to the start of their shift. Cross Reference F759 Findings: a. A review of the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses including hemiplegia (a severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (a mild or partial weakness or loss of strength on one side of the body) following cerebral infarction (a stroke that occurs when blood flow to the brain is blocked) affecting left non-dominant side, hypertension (high blood pressure), cardiomegaly (a condition where the heart is larger than normal), and atrial fibrillation (AF, abnormal heartbeat). During a review of Resident 50's Minimum Data Set (MDS - a resident assessment tool) dated 9/26/24, the MDS indicated Resident 50's cognitive skills (mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was moderately impaired. Resident 50's MDS indicated the resident required setup for eating and oral hygiene, required substantial assistance for personal hygiene and was dependent on staff physical assistance. During a review of Resident 50's History and physical (H&P) dated 2/29/2024, the H&P indicated Resident 50 had the capacity to understand and make decisions. During a review of Resident 50's Order Summary Report, the Order Summary Report indicated Resident 50's orders included: -Apixaban (Eliquis, an anticoagulant, a blood thinner) 5 (five) milligrams (mg - unit of measure of weight) give one tablet by mouth every 12 hours, scheduled at 9 a.m., and 9 p.m., for AF, order date 4/26/2023. -Amlodipine (Norvasc, a medication used to treat high blood pressure) 5 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for hypertension, hold if systolic blood pressure (SBP, when the heart beats, top number) is less than 110 millimeters of mercury [mm Hg]), (mmHg - unit of measure), order date 8/28/2024. -Aspirin Enteric Coated (EC) 81 mg, give one tablet by mouth one time a day, scheduled at 9 a.m., for myocardial infarction (MI, also known as a heart attack, occurs when blood flow to the heart is blocked) prophylactically (PPX, measures designed to preserve health), order date 6/17/2020. During a review of Resident 50's, Care Plans, the care plans for Resident 50 indicated the following: -Black Box Warning (is a serious warning given by the Food and Drug Administration [FDA] for drugs or drug classes that may cause serious harm or death) for use of Apixaban (Eliquis), dated 3/27/2020. Resident 50's care plan goal indicated; the resident will not experience side effects/ interactions with the use of Apixaban (Eliquis). -Anticoagulant therapy, Apixaban for atrial fibrillation, at risk for active bleeding, revised 2/6/2025. Resident 50's care plan intervention indicated give Apixaban 5 mg by mouth every 12 hours for AF. Resident/family/caregiver teaching to include the following: take/give medication at the same time each day. -Hypertension (HTN) related to lifestyle and stroke, dated 3/27/2020. The interventions included instructions to give anti-hypertensive medications as ordered. Monitor for side effects such as orthostatic hypotension (a sudden drop in blood pressure when standing) and increased heart rate (tachycardia) and effectiveness. -Risk for repeat Cardiovascular Accident (CVA) as resident had a CVA prior to admission, date revised 2/6/2025, and goal indicated to minimize risk with interventions. Interventions indicated, administer medication(s) as ordered. -Risk for adverse reaction related to polypharmacy (the simultaneous use of multiple drugs by a single patient, for one or more conditions), revision date 2/6/2025. Resident 50's care plan interventions included to review resident's medications with MD/Consultant pharmacist for proper dosing, timing and frequency of administrations. During a concurrent observation and interview on 2/25/2025 at 10:17 a.m., with a Licensed Vocational Nurse (LVN) 3 on Station 2 at Medication Cart (MedCart) 2, LVN 3 stated she was preparing the morning medications for Resident 50 that was scheduled for 9 a.m. During a medication pass observation on 2/25/2025 at 10:20 a.m., with LVN 3, LVN 3 prepared and administered Resident 50's morning medications, scheduled for 9 a.m., administration that included Apixaban 5 mg, one tablet, Amlodipine 5 mg, one tablet, and Aspirin Enteric Coated (EC) 81 mg, one tablet. During an interview on 2/25/2025 at 10:32 a.m., Resident 50 stated she usually gets her medications late, but she knew the nurses were very busy. During an interview on 2/25/2025 at 10:38 a.m., LVN 3 stated she had 17 more residents to administer morning medications to that were scheduled for 9 a.m LVN 3 stated the supervisor and Director of Nursing (DON) was made aware of the heavy load, which included four of her 32 residents received medications through a gastrostomy tube (GT - a tube inserted through the belly that brings nutrition, fluids, and medications directly to the stomach), which takes more time and that she was not able to pass medications to all of residents on time. During an earlier interview on 2/25/2025 at 10:11 a.m., with LVN 1, on Station 2, at MedCart 3, LVN 1 stated he had 12 more residents to pass medications scheduled for 9 a.m., out of a total of 27 residents, and usually finished passing morning medications each day around 11:30 a.m. LVN 1 stated he notified a Registered Nurse Supervisor. LVN 1 stated, It can be overwhelming, especially when you are trying to give the best care, not rush residents, and not make mistakes. During an interview on 2/25/2025 at 1:32 p.m., the DON stated licensed nurses should administer medications within an hour of the scheduled administration time or up to an hour after the scheduled administration time. The DON stated the resident's physician must be notified if resident's medications would be administered outside of the time frame and then following the physician's instructions, if it was okay to administer the medication. During a record review of Resident 50's Medication Administration Audit Report, Resident 50's Medication Audit Report was reviewed between 2/1 to 2/25/2025. The Medication Administration Audit Report indicated Resident 50 was administered apixaban, amlodipine, and aspirin late and for apixaban less than 12 hours from the next scheduled dose as follow on: -2/2/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 3:09 p.m. (six hours and nine minutes late). -2/2/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:33 p.m., five hours and 24 minutes after the last dose was given at 3:09 p.m., instead of the ordered 12 hours between doses. -2/4/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:57 a.m. (one hour and 57 minutes late). -2/8/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:35 a.m. (one hour and 35 minutes late). -2/9/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 1:55 p.m. (four hours and 55 minutes late). -2/9/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:17 p.m., six hours and 22 minutes after the last dose was given at 1:55 p.m., instead of the ordered 12 hours between doses. -2/12/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:58 a.m. (one hour and 58 minutes late). -2/13/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 11:08 p.m. (two hours and eight minute late). -2/16/2025 apixaban 5 mg, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 1:02 p.m. (four hours and two minutes late). -2/16/2025 apixaban 5 mg scheduled for administration at 9 p.m., was administered at 8:43 p.m., seven hours and 41 minutes after the last dose was given at 1:02 p.m., instead of the ordered 12 hours between doses. -2/21/2025 apixaban, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 10:33 a.m. (one hour and 33 minutes late). -2/22/2025 apixaban 5 mg scheduled for administration at 9 a.m., was documented administered at 6:03 p.m. (nine hours and three minutes late). -2/22/2025 apixaban 5 mg scheduled for administration at 9 p.m., was documented administered at 8:51 p.m. two hours and 48 minutes after the last dose was given at 6:03 p.m., instead of the ordered 12 hours between doses. -2/23/2025 apixaban, amlodipine, and aspirin scheduled for administration at 9 a.m., was documented administered at 11:10 a.m. (two hours and 10 minutes late) -2/22/2025 apixaban 5 mg scheduled for administration at 9 p.m., was documented administered at 9:22 p.m., ten hours and 22 minutes after the last dose was given at 11:10 a.m., instead of the ordered 12 hours between doses. b. A review of Resident 10's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including Type II diabetes (DM, a condition that occurs when the body does not use insulin properly, leading to high blood sugar levels), hypertension (high blood pressure), myocardial infarction (MI), and AF. During a review of Resident 10's, MDS dated [DATE], the MDS indicated Resident 10's cognitive skills for daily decision-making was moderately impaired. During a review of Resident 10's Order Summary Report, the Order Summary Report indicated Resident 10 had orders for: -Eliquis 2.5 mg, to give one tablet by mouth two times a day scheduled at 9 a.m. and 5 p.m., for AF, with an order date of 3/27/2024. -Eliquis: Monitor for signs and symptoms of bleeding (abnormal or unexplained bruising, petechiae (tiny spots of bleeding under the skin), internal bleeding, nosebleeds, bleeding gums, abnormal bleeding) by (+) Yes or (-) No. Notify MD if (+) every shift (Day shift, Evening Shift, and Night Shift), order date 11/10/2023. -Metformin 500 mg, one tablet by mouth four times a day for DM, give with food, order date 11/2/2023 During a review of Resident 10's, Care Plans, the care plans indicated: -Resident 10 had High Risk for Bleeding, Bruising, and/or Skin Discoloration related to anticoagulant therapy, Eliquis, dated 12/1/2022. Resident 10's care plan goal indicated, the resident will remain free of abnormal bleeding or bruising, and the care plan intervention indicated, administer medications as ordered and monitor for side effects. Observe / record / report to MD as needed, abnormal or unexplained bruising. -Resident 10 had a Black Box Warning for use of Metformin (Glucophage) for diabetes mellitus (DM), revised 2/8/2025. Resident 10's care plan goal indicated the resident will not experience side effect/ interactions with the use of Metformin, and the care plan interventions included, Black Box Warning, post marketing cases of metformin-associated lactic acidosis (lactic acid build up in the bloodstream) have resulted in death, hypothermia (body loses heat faster than it can produce heat), hypotension (low blood pressure), and resistant bradyarrhythmia (an irregular heartbeat that's slower than normal). The onset of metformin-associated lactic acidosis is often subtle, accompanied only by myalgias (muscle pain), respiratory distress (difficulty to breath), somnolence (drowsiness), and abdominal pain. During a review of Resident 10's Nursing Progress Notes dated 2/24/2025 at 8:46 a.m., Resident 10's progress notes indicated, On monitoring for discoloration to right wrist. Resident still noted with discoloration in affected wrist. During a record review of Resident 10's Medication Administration Audit Report, Resident 10's Medication Audit Report was reviewed between 2/1/2025 to 2/25/2025, the Medication Administration Audit Report indicated resident was administered apixaban less than 8 hours from the next scheduled dose as follow on: -2/17/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:12 a.m. (two hours and 12 minutes late). -2/24/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 2:29 p.m. (five hours and 29 minutes late). -2/24/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:17 p.m., two hours and 48 minutes after the last dose was given at 2:29 p.m., instead of the ordered eight hours between doses. -2/25/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 1:34 p.m. (four hours and 34 minutes late). -2/17/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 11:10 a.m. (over three hours late). -2/18/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 10:09 a.m. (over two hours late). -2/17/2025 metformin 500 mg, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 9:57 a.m. (two hours late). -2/20/2025 metformin, scheduled for administration at 5:30 p.m., to be given with food was documented administered at 7:39 p.m. (two hours late). -2/24/2025 metformin, scheduled for administration at 7:30 a.m., to be given with food was documented administered at 2:28 p.m. (almost seven hours late). -2/17/2025 metformin, scheduled for administration at 5:30 p.m., to be given with food was documented administered at 5:17 p.m. (less than three hours since last administration of 2:38 p.m.). c. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was admitted to the facility on [DATE] with diagnoses that included repeated falls, cardiomegaly, hypertension, and atrial flutter (a condition in which the heart's upper chambers [atria] beat too quickly) During a review of Resident 54's, MDS dated [DATE], the MDS indicated Resident 54's cognitive skills for daily decision-making was severely impaired. A review of Resident 54's H&P dated 6/22/2024 indicated, She has been in ED (emergency department) three times in three days following falls at her SNF (a previous skilled nursing facility). First visit on 6/15/2024 after a witnessed fall while getting up from bed and tempted to use her walker and fell. Resident 54's H&P indicated the resident had persistent atrial fibrillation and was on anticoagulant therapy, Fall Risk Precautions, and did not have medical decision making capacity. During a review of Resident 54's Order Summary Report for February 2025, the Order Summary Report indicated Resident 54 had an order for Eliquis 2.5 mg, to give one tablet by mouth two times a day scheduled at 9 a.m., and 5 p.m., for AF / atrial flutter. During a review of Resident 54's Care Plans revised 1/5/2025, the care plans indicated Resident 54: -was at risk for falls related to gait/balance problems, at risk for fall due to history of repeated falls prior to admission to facility. The most recent fall was on 12/25/2024. -has Black Box Warning for use of apixaban (Eliquis): atrial fibrillation, resident's care plan goal revised 10/14/2024 indicated Resident 54 will not experience side effects/interactions with the use of apixaban (Eliquis). During a record review of Resident 54's Medication Administration Audit Report, Resident 54's Medication Audit Report was reviewed between 2/1/2025 to 2/25/2025, the Medication Administration Audit Report indicated resident was administered apixaban less than 8 hours from the next scheduled dose as follows on: -2/17/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:48 a.m. (two hours and 48 minutes late). -2/17/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:42 p.m., five hours and 54 minutes after the last dose was given at 11:48 a.m., instead of the ordered eight hours between doses. -2/18/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 11:40 a.m. (two hours and 40 minutes late). -2/18/2025 apixaban 2.5 mg scheduled for administration at 5 p.m., was administered at 5:14 p.m., five hours and 54 minutes after the last dose was given at 11:40 a.m., instead of the ordered eight hours between doses. -2/20/2025 apixaban 2.5 mg, scheduled for administration at 9 a.m., was documented administered at 12:03 p.m. (three hours and three minutes late). During an interview on 2/25/2025 at 3:06 PM with DON, the DON provided a list of 23 residents which included Residents 8, 10, 11, 32, 54, 66, 95, 99. Eleven of the 23 residents were on Station 2, MedCart 2 and 12 of the 23 residents were on Station 2, MedCart 3, that were administered morning medications scheduled for 9 a.m., over 60 minutes pass the scheduled administration time, close to the next scheduled dose, and/ or not in accordance with the physician's orders between 2/17/2025 - 2/25/2025. The DON stated there was no documentation that the physician was called prior to LVN 1 and LVN 2 administering medications late to residents on Station 2 MedCart 2, and to residents on Station 2 MedCart 3 on 2/25/2025. The DON stated the physician should have been called before administering medications late to residents and they were working to notify the physicians now. d. During a review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including seizures (a sudden, uncontrolled burst of electrical activity in the brain that can cause temporary changes in behavior, movement, sensation, or awareness), cerebral palsy (a brain disorder that affects a person's ability to move and maintain balance and posture), and cerebral infarction (stroke, death of brain tissue caused by a lack of blood flow) due to occlusion or stenosis of right middle cerebral artery (a narrowing or blockage of the blood vessel that supplies blood to the brain). During a review of Resident 1's, MDS dated [DATE], the MDS indicated Resident 1's cognitive skills (mental activities including thinking, reasoning, understanding, learning, and remembering) for daily decision-making was intact. Resident 1's MDS indicated the resident required set up for eating, moderate assistance for oral hygiene and was dependent on staff for physical assistance. During a review of Resident 1's, H&P dated 1/29/23 the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Order Summary Report, the Order Summary Report indicated Resident 1 had an order for Depakote (valproic acid) Solution 250 milligrams (mg - unit of measure of weight) per 5 (five) milliliters (ml - unit of measure of volume) 250 mg/5 ml, to give 5 ml by mouth three times a day, scheduled at 9 a.m., 1 p.m., and 5 p.m., for seizure, order date 2/23/2023. During a review of Resident 1's, Care Plan revised 2/7/2025, the care plan indicated Resident 1 had a Black Box Warning (a serious warning given by the Food and Drug Administration (FDA) for drugs or drug classes that may cause serious harm or death) for use of Depakote (valproic acid), indication for seizures, care plan goal indicated the resident will not experience side effects/interactions (when one drug alters the effectiveness of another drug) with the use of Depakote. Resident 1's care plan intervention indicated, Black Box Warning .monitor resident closely . Hepatic failure resulting in fatalities has occurred in patients receiving valproate .Severe or fatal hepatotoxicity may be preceded by nonspecific symptoms such as malaise (a general feeling of being unwell), weakness, lethargy (lack of energy), facial edema (swelling), and vomiting. In patients with epilepsy (a neurological condition that causes unprovoked, recurrent seizures [is a sudden rush of abnormal electrical activity in your brain]), a loss of seizure control may also occur. During a record review on 2/27/25 at 1:30 p.m., with the Director of Nursing (DON), Resident 1's Medication Administration Audit Report was reviewed for 2/17/2025 to 2/26/2025, the Medication Administration Audit Report indicated the following: -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 1:37 p.m., on 2/20/2025, which was four hours and 37 minutes later than scheduled and dose. The valproic acid ordered for 1 p.m. was given at 2:16 p.m. on 2/20/2025, which was 39 minutes after the last dose was given at 1:37 p.m. -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 10:58 a.m., on 2/22/2025, which was one hour and 58 minutes later than scheduled dose and the valproic acid ordered for 1 p.m. was given at 12:12 p.m. on 2/22/2025, which was one hour and 14 minutes after the last dose was given at 10:58 a.m. -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 11:21 a.m., on 2/23/2025, which was two hours and 21 minutes later than scheduled and the valproic acid ordered for 1 p.m. was given at 12:54 p.m. on 2/23/2025, which was one hour and 33 minutes after the last dose was given at 11:21 a.m. -Resident 1's scheduled 9 a.m. dose of valproic acid was given at 12:33 p.m., on 2/25/2025, which was three hours and 33 minutes later than scheduled and the valproic acid ordered for 1 p.m. was given at 2:28 p.m. on 2/25/2025, which was one hour and 55 minutes after the last dose was given at 12:33 p.m. During an interview on 2/27/2025 at 1:38 p.m., the DON stated giving a seizure medication 40 minutes after the first dose or close to the next scheduled dose was not acceptable. The DON stated this would be considered double dosing and could cause Resident 1 to experience adverse reactions (unwanted or harmful effect that can occur when taking a drug or undergoing a medical procedure) and could cause Resident 1 to reach toxic levels of the valproic acid, could trigger a seizure or lead the resident becoming hospitalized for uncontrolled seizures or death. During a review of the facility's Policy and Procedure (P&P) titled, Medication Administration - General Guidelines, dated 10/2012, the P&P indicated the facility had sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medications were administered in accordance with written orders of the prescriber. Medications were administered within (60 minutes) of scheduled time, except before or after meal orders, which are administered (based on mealtimes). e. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including seizures and traumatic subdural hemorrhage (a brain injury that occurs when blood builds up between the brain and the skull) with loss of consciousness of unspecified duration During a review of Resident 37's MDS dated [DATE], the MDS indicated Resident 37's cognitive skills for daily decision-making was moderately impaired. Resident 37's MDS indicated the resident required set up for eating and was dependent on staff for physical assistance with oral hygiene, bathing, and dressing, During a review of Resident 37's, H&P dated 3/31/22, the H&P indicated Resident 37 can make needs known but cannot make medical decisions. During a review of Resident 37's Order Summary Report, the Order Summary Report for February 2025 indicated Resident 37 had an order for Keppra (levetiracetam) 500 mg, to give one tablet by mouth two times a day, scheduled at 9 a.m. and 5 p.m., for seizures. During a review of Resident 37's, Care Plan revised 2/7/2025, the care plan indicated Resident 37 had a seizure disorder and the care plan intervention indicated to give seizure medication as ordered by doctor, to monitor and document side effects and effectiveness. During a record review, Resident 37's Medication Administration Audit Report was reviewed for 2/17/2025 to 2/26/2025, the Medication Administration Audit Report indicated the following: -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 2:12 p.m., on 2/20/2025, which was five hours and 12 minutes later than scheduled and the levetiracetam ordered for 5 p.m. was given at 5:47 p.m. on 2/20/2025, which was three hours 35 minutes after the last dose was given at 2:12 p.m. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 11:01 a.m., on 2/22/2025, two hours later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 11:24 a.m., on 2/23/2025, two hours and 24 minutes later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 12:11 p.m., on 2/24/2025, over three hours later than scheduled. -Resident 37's scheduled 5 p.m. dose of levetiracetam was given at 10:54 p.m., on 2/24/2025, almost six hours later than scheduled. -Resident 37's scheduled 9 a.m. dose of levetiracetam was given at 12:06 p.m., on 2/25/2025, which was three hours and six minutes later than scheduled and the levetiracetam ordered for 5 p.m. was given at 5:29 p.m. on 2/20/2025, which was four hours 23 minutes after the last dose was given at 12:06 p.m. During an interview on 2/26/2025 at 1:37 p.m., with the facility's Pharmacist Consultant (PC) stated the facility was supposed to have a process in place to have another nurse help to ensure medication administration did not run into the noon or next medication administration time if residents had medications scheduled for two or three times a day. The PC stated he suggested to the facility's Assistant Director of Nursing (ADON) and the DON several months ago, having another nurse to assist with medication pass to prevent late medication administration. The PC stated when medications were administered over three hours late, that was not acceptable practice. The PC stated it was important to give apixaban as ordered because of the pharmacokinetics (the movement of drug into, though, and out of the body) of the medication to maintain therapeutic effects (the response(s) after a treatment of any kind, the results of which were judged to be useful or