**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility documentation, facility policy and interviews for three (3) of seven (7) sampled residents (Residents #1, #2 and #6) who were reviewed for medication administration, the facility failed to ensure the residents received scheduled anti-anxiety medication, narcotic pain medication, or both for agitation and comfort as prescribed by the physician. The failures resulted in the finding of Immediate Jeopardy. The findings include:1. Resident #1's diagnoses included malignant neoplasm of the ovaries, schizoaffective disorder, anxiety, delusional disorders, restlessness and agitation and depressive disorder. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) of zero (0) out of fifteen (15) indicating memory recall deficits. The Resident Care Plan dated 4/28/25 identified Resident #1 received hospice services for a diagnosis of ovarian cancer. Interventions directed to administer medications per the physician's orders. a. A physician's order dated 1/11/25 directed to administer morphine sulfate oral solution 100 milligrams (mg) in 5 milliliters (mL), give 40 mg sublingually (under the tongue) every four (4) hours for pain, to be given around the clock. Review of the June 2025 Medication Administration Record (MAR) identified the morphine sulfate was not administered from 6/5/25 at 8:00 AM through 6/9/25 at 12:00 PM therefore twenty-six (26) doses were omitted. Upon further review, doses were not administered on 6/25/25 at 8:00 PM and 6/26/25 at 8:00 AM. The nurse's electronic MAR (eMAR) notes dated 6/5/25 through 6/9/25 identified the morphine sulfate was not administered because the medication was not available and was on order. Both the nurse's note and eMAR note dated 6/8/25 identified Resident #1 was noted to be crying, moaning, and refused care and Tylenol (pain reliever) was administered. Review of the pain assessments from 6/7/25 to 6/9/25 identified pain levels of zero (0) through eight (8) on a scale of zero (0) to ten (10). b. A physician's order dated 6/26/25 directed to administer morphine sulfate oral solution 100 mg in 5 mL, give 1.5 mL sublingually every four (4) hours as needed for pain and start morphine sulfate Extended Release (ER) 60 mg tablet, give two (2) tablets (120 mg) by mouth every twelve (12) hours for pain. Review of the June and July 2025 MAR identified the morphine sulfate ER 120 mg was not administered from 6/26/25 12:00 PM when it was ordered until 7/4/25 when it was discontinued, Resident #1 had gone without the scheduled pain control, a total of sixteen (16) doses and the as needed morphine sulfate oral solution was not administered in it's place. Review of the pain assessments from 6/26/25 to 6/30/25 identified pain levels of zero (0) through five (5). The nurse's eMAR notes dated 6/26/25 through 7/4/25 identified the morphine sulfate ER 120 mg was not administered because the medication was on order and not available. Interview with Person #6 (pharmacy manager) on 8/20/25 at 8:40 AM identified on 6/2/25 when the pharmacy received a script for the morphine sulfate oral solution the quantity was not identified so they called the facility for clarification but never received follow-up. Person #6 reported the facility did not reach out for an update until 6/9/25 which by that time twenty-six (26) doses had been missed and the facility authorized the pharmacy to bill for 90 mL, three (3) bottles for a sixteen (16) day supply. Person #6 explained that on 6/26/25 when the morphine sulfate ER tablets were first ordered, the pharmacy called the facility for clarification because the script was dosed incorrectly, and the facility then never called back or communicated with them until 6/30/25 when the pharmacy informed the facility the dosage was on backorder and unavailable. Person #6 identified going without morphine from 6/26/25 through 7/1/25 could have caused increased discomfort, respiratory issues, pinpoint pupils, tremors, sweats, restlessness, nausea/vomiting and insomnia. Person #6 reported that the delay in the medication getting sent to the facility was due to the facility's lack in communication and not sending scripts prior to exhausting the supply. c. A physician's order dated 2/24/25 directed to administer lorazepam intensol oral concentrate 2 mg per mL, give 4 mg by mouth every four (4) hours for agitation and/or pain. Review of the MAR with associated eMAR notes from May through July 2025 identified the lorazepam was not administered ten (10) times in May 2025, thirteen (13) times in June 2025 and twenty-three (23) times in July 2025, as the medication was unavailable, on order or the resident was sleeping. The May 2025 MAR identified that from 4:00 PM on 5/22/25 through 4:00 AM on 5/24/25 there were ten (10) doses of lorazepam oral contrate not administered. Review of nurse's notes from 5/22/25 through 5/25/25 failed to reflect documentation that the charge nurses informed the nursing supervisors, and the supervisors informed the provider. The June 2025 MAR identified that from 8:00 AM on 6/2/25 until 4:00 AM on 6/3/25 there were six (6) doses of lorazepam not administered, on 6/15/25 from 12:00 PM through 12:00 AM on 6/16/25 four (4) doses were not administered and on 6/18/25 through 6/19/25 there were four (4) doses not administered because the medication was on order. Review of the Controlled Drug Record dated 6/16/25 identified 150 mL (12.5 day supply) of lorazepam was delivered to and signed for by the facility on 6/16/25, so Resident #1 should have received the lorazepam on 6/18/25 and 6/19/25 as ordered. Review of nurse's notes from 6/1/25 through 6/20/25 failed to reflect documentation that the charge nurses informed the nursing supervisors, and the supervisors informed the provider. Review of behavior monitoring from 5/1/25 through 8/1/25 with associated eMAR progress notes identified that on 6/8/25 at both 12:00 AM and 12:00 PM Resident #1 was noted to be crying and moaning. On 6/9/25 Resident #1 was noted to be anxious (last doses withheld/missed on 6/2/25 and 6/3/25). The July 2025 MAR identified that from 12:00 PM on 7/5/25 until 4:00 PM on 7/7/25 there were thirteen (13) doses of lorazepam not administered, and twelve (12) doses not administered from 4:00 PM on 7/26/25 until 4:00 PM on 7/28/25. Review of the nurse's notes from 7/4/25 through 7/29/25 failed to reflect documentation that the charge nurses informed the nursing supervisors, and the supervisors informed the provider. Review of behavior monitoring from 5/1/25 through 8/1/25 with associated eMAR progress notes identified on 6/8/25 at both 12:00 AM and 12:00 PM Resident #1 was noted crying and moaning. On 6/9/25 Resident #1 was noted to be anxious (last doses withheld/missed on 6/2/25 and 6/3/25). Review of behavior monitoring on 7/1/25 at 4:00 AM Resident #1 was noted with behaviors, but no follow-up note was documented to explain what the behaviors observed were. On 7/7/25 at 11:43 PM Resident #1 was crying and calling out and on 7/8/25 at 1:31 PM Resident #1 was noted with increased anxiety (last doses withheld/missed 7/5/25 to 7/7/25). The Advanced Practice Registered Nurse (APRN) note dated 7/7/25 identified she had been notified on 7/7/25 that Resident #1's morphine sulfate ER tablets and lorazepam intensol oral concentrate had not arrived from either the facility's pharmacy or the hospice pharmacy and Resident #1 was withdrawing from both the morphine and lorazepam and Resident #1 stated he/she felt like they were crawling out of their skin. The note reported Resident #1 was staring up at the ceiling, grinding his/her teeth and was notably anxious. The note identified the APRN re-faxed the scripts to the pharmacy, directed to continue the morphine concentrate as needed, would start lorazepam 4 mg tablets every four (4) hours around the clock until the lorazepam concentrate was delivered, and order a fentanyl patch 50 micrograms (mcg) to be applied every seventy-two (72) hours until the morphine sulfate ER tablets were delivered to the facility. Review of physician's orders for July 2025 failed to identify the order for the lorazepam 4 mg tablets every four (4) hours around the clock was entered or initiated. The nurse's note dated 7/30/25 at 2:46 PM, after not receiving the lorazepam from 7/26/25 until 7/28/25, two (2) days twelve (12) doses, identified Resident #1 was combative, refusing medications and care and on 8/1/25 at 9:46 AM Resident #1 was calling out, yelling, and was noted to be paranoid. The APRN note dated 7/31/25 identified Resident #1 was agitated, refusing medications, attempting to hit others and actively hallucinating and hospice was concerned Resident #1 may require a psychiatric hospitalization. A hospice note dated 7/31/25 identified Resident #1 was irritable, hallucinating, refusing medications and meals and struck a nurse the previous day due to agitation. The note indicated if the facility was unable to manage Resident #1's behaviors with the current regimen they should follow-up with the medical director for the behaviors and Resident #1 may require transport to next level of care. Interview with Person #3 (facility pharmacy representative) on 8/15/25 at 2:07 PM and review of the May 2025 MAR identified Resident #1 missed doses of lorazepam from 4:00 PM on 5/22/25 through 4:00 AM on 5/24/25. Person #3 indicated she had no documentation identifying the facility contacted them from 5/20/25 through 5/22/25 for a refill but the pharmacy did receive a new script on 5/23/25 and the pharmacy delivered the lorazepam on 5/24/25 at 3:55 AM because the facility did not request a STAT delivery. Person #3 explained she was not aware until 8/15/25, that with the 5/23/25 refill order, the pharmacy staff incorrectly calculated the amount and supply and set the next refill date to be available in eighteen (18) days when it should have been eligible for a refill in seven and one half (7.5) days. Person #3 identified the facility called on 6/2/25 to inquire about the next delivery and the facility was told the script could not be refilled until 6/11/25 so the Assistant Director of Nursing ADON approved a fifteen (15) day supply to be billed to the facility, which was processed and delivered on 6/3/25, however, Resident #1 missed six (6) doses of lorazepam from 6/2/25 through 6/3/25. Interview with Person #2 (Hospice clinical manager) on 8/15/25 at 10:22 AM identified due to ongoing issues with the facility's pharmacy not delivering Resident #1's narcotics timely where Resident #1 was missing doses, they started utilizing their own pharmacy on 7/9/25 and started having their hospice nurse conduct narcotic count with a facility nurse several times weekly so that they (hospice) were aware when the counts were low. Person #2 was unable to identify why hospice was not aware that Resident #1 ran out of the lorazepam from 7/26/25 until 7/28/25. Person #2 explained there was a cycle where hospice would adjust Resident #1's medications, get Resident #1 stable, then the facility would run out of the medications again and Resident #1 would become anxious and display behaviors. Interview with APRN #1 on 8/15/25 at 1:56 PM identified that on 7/7/25 she was notified Resident #1 had not received the morphine and lorazepam for several days and although she wrote in the note dated 7/7/25 Resident #1 was withdrawing from both the morphine and lorazepam due to the supply being unavailable, she was going to order lorazepam 4 mg tablets every four (4) hours around the clock until the lorazepam concentrate was delivered. APRN #1 indicated she could not recall being notified from May 2025 through July 2025 that the facility would run out of Resident #1's supply of lorazepam. APRN #1 identified the licensed nurses should be notifying a provider for all missed doses of medication so that they can order an alternative until the supply is delivered. APRN #1 explained that Resident #1 missing the morphine and lorazepam doses could have contributed to the behaviors and discomfort Resident #1 was experiencing on 6/8/25, 6/9/25, 7/7/25 and 7/30/25 per the nurses' notes. Interview with Person #4 (Hospice Manager) on 8/18/25 at 11:08 AM identified the facility did not notify them until 7/28/25 that the supply of lorazepam was exhausted on 7/26/25, two (2) days later, and the facility requested a STAT delivery. The Hospice Manager explained although their nurse would do narcotic count with the facility's nurse twice a week, they did not start the count of the lorazepam until after the supply was delivered on 7/29/25. Interview with Person #5 (pharmacist) on 8/19/25 at 1:40 PM identified lorazepam intensol withdrawal symptoms can include increased anxiety, combativeness, agitation, hallucinations, nausea/vomiting, insomnia, tremors and seizures. Person #5 indicated the behaviors Resident #1 exhibited on 6/8/25, 6/9/25, 7/7/25, 7/8/25, 7/30/25 and 7/31/25 could have been related to withdrawal from the lorazepam, and for a resident on as high of a dose and frequency as Resident #1, he/she could have started withdrawing anywhere between one (1) and five (5) days depending on the resident. Interviews with charge nurses Licensed Practical Nurse (LPN) LPN #2, LPN #3, LPN #4, LPN #5, LPN #7, LPN #10, and LPN #11 identified they had been told by the facility prior, to August 2025 that they were not to call the pharmacy or the provider for medication issues, they were to notify the nursing supervisor on duty and the notifications were the supervisors responsibility. They stated they were not aware the provider had to be notified for each missed administration, with multiple staff stating another staff member communicated to them the pharmacy was notified and the supervisor was aware, so they took their word for it and did not notify the nursing supervisor that they still had not received a delivery and the medications continued to be omitted. Interviews with nursing supervisors, Registered Nurse (RN), RN #1 and RN #5 identified the charge nurses did not notify them consistently for all missed morphine and lorazepam doses between May and July 2025, stating if the charge nurses had informed them, they would have notified the pharmacy and provider. RN #1 and RN #5 reported when charge nurses did notify them, they did not always document in the clinical record when they had contacted the pharmacy or communicated with the provider. RN #5 stated she would not call the provider on the 11PM to 7AM shift for missed medication administration but would instead pass it on to the 7AM to 3PM shift to notify APRN #1. Interview with the Director of Nursing (DON) on 8/18/25 at 1:15 PM identified the facility should have never run out of the morphine or lorazepam, stating she was under the impression the hospice nurse was counting all of Resident #1's narcotic medications with the facility charge nurses twice weekly since Resident #1 was assigned to hospice's pharmacy early July 2025. The DON explained she had not observed the counts, and notes were not taken when the counts occurred. The DON identified the charge nurses should have been notifying the nursing supervisor at least twenty-four (24) hours prior to the medication being exhausted and requesting a refill, in case there were issues with the script. The DON identified that for all doses of medication not administered, the charge nurse was to call the pharmacy to inquire on when the medication would be delivered, then notify the nursing supervisor of the missed administration so the nursing supervisor can contact the provider, and the charge nurses should be following-up with the nursing supervisor and ask if any new orders were obtained. 2. Resident #6's diagnoses included chronic pain, osteoarthritis (degenerative joint disease where the tissues in the joints break down over time), kyphosis (excessive forward curve of the spine which can cause back pain and stiff muscles) and anxiety disorder. A physician's order dated 6/3/24 directed to administer hydrocodone/acetaminophen 5-325 mg tablet, give one (1) tablet every evening for pain. The annual Minimum Data Set assessment dated [DATE] identified Resident #6 had a Brief Mental Interview for Mental Status (BIMS) of fifteen (15) out of fifteen (15) indicating Resident #6 was alert and oriented to person, place, and time. The Resident Care Plan dated 6/12/25 identified Resident #6 was at risk for pain related to osteoarthritis, osteoporosis (weak and brittle bones), chronic pain, headache syndrome and intestinal and rectal fistulas (abnormal connection between two parts inside the body that don't normally connect). Interventions directed to administer pain relief medications per the physician's order, to anticipate the resident's need for pain relief and respond immediately to any complaints of pain and to monitor and record characteristics of the pain. Review of the July 2025 MAR identified the hydrocodone/ acetaminophen was not administered 7/21/25 through 7/24/25, four (4) days and to see progress notes. The MAR identified pain assessments were completed every shift and no pain was noted from 7/21/25 through 7/24/25. The eMAR progress notes dated 7/21/25 through 7/24/25 identified the hydrocodone/ acetaminophen was not administered because it was not available and on order. Review of the Controlled Drug Record sheets identified the hydrocodone/acetaminophen had not been signed out from 7/21/25 through 7/24/25. Interview with LPN #2 on 8/18/25 at 9:48 AM identified that although she administered the last tablet of hydrocodone/acetaminophen to Resident #6 on 7/20/25 she could not recall if she had refilled the medication, contacted the pharmacy or notified the nursing supervisor. LPN #2 indicated she also did not administer the hydrocodone/acetaminophen on 7/21/25 through 7/23/25 because the medication was out of stock and not available, she did not notify the supervisor each day or call the pharmacy to inquire about the medication, explaining she did not have time to call the pharmacy and was unaware the nursing supervisor and provider had to be notified for each missed administration. Interview with Person #6 (Pharmacist Manager) on 8/20/25 at 8:40 AM identified they had no record the facility contacted them in July 2025 to inquire about a refill for Resident #6's hydrocodone/acetaminophen tablets. Person #6 reported the pharmacy received a new script on the afternoon of 7/24/25 and the facility received the hydrocodone/acetaminophen on 7/25/25. 3. Resident #2's diagnoses included dementia with behavioral and mood disturbances and anxiety disorder. The Resident Care Plan dated 7/30/25 identified that Resident #2 utilized psychotropic medications related to diagnoses of adjustment disorder, depression, anxiety, Alzheimer's dementia, delusional disorder and mood disorder. Interventions directed to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. The admission Minimum Data Set assessment dated [DATE] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of three (3) out of fifteen (15) indicating poor memory recall. The psychiatric APRN note dated 8/5/25 identified she was asked to evaluate Resident #2 for mood and anxiety, Resident #2 could become angry with an explosive temper without provocation, hostile with staff members of color and combative with care, was confused and could not recall anything for longer than a few minutes so when Resident #2 becomes agitated it was best to walk away and reapproach after a few minutes. The note identified they would trial lorazepam three (3) times daily to see if it improves the behaviors. A physician's order dated 8/5/25 directed to administer lorazepam oral concentrate 2 mg per mL, give 0.5 mL by mouth three (3) times daily for anxiety/agitation/irritability. Review of the August 2025 MAR identified the lorazepam oral concentrate was not administered to Resident #2 on 8/5/25 at 12:00 PM or 4:00 PM, 8/6/25 at 8:00 AM, 8/7/25 at 4:00 PM or 8/8/25 at 8:00 AM and 12:00 PM. Review of the nurse's notes and eMAR notes dated 8/5/25 through 8/8/25 identified the lorazepam was either unavailable, Resident #2 refused the medication or the resident was sleeping. Interview with LPN #1 on 8/19/25 identified although she did not administer the lorazepam to Resident #2 on 8/5/25, 8/6/25 and 8/8/25 she was unaware she had to notify the nursing supervisor for all missed medication administrations and refusals so the nursing supervisor can notify the provider for possible alternative orders. Interview with the Person #6 (Pharmacist Manager) on 8/20/25 at 8:40 AM identified the pharmacy received the script on 8/5/25 at 5:30 PM for the lorazepam oral concentrate for Resident #2, reporting that it was not requested STAT (immediately) so it was sent on the 9:00 PM run and was signed for by the facility on 8/6/25 at 2:31 AM. Interview with the DON on 8/19/25 at 3:42 PM identified that she was not aware Resident #2 and Resident #6 did not receive the scheduled narcotics as ordered in July and August 2025. The DON indicated that the pharmacy and provider should have been contacted for all unavailable medications, medication refusals and missed administrations and this should be documented in the clinical record. The DON explained residents should be woken up for the scheduled narcotic medications. The DON identified the facility's emergency stock for lorazepam intensol oral concentrate, morphine sulfate oral solution and hydrocodone/acetaminophen tablets had been depleted prior to 6/17/25 and the supply was not refilled. Review of the Administration of Medications policy dated 7/2023 directed, in part, that medications are to be given at the time ordered or within 60 minutes before or after the time designated. Medication errors and adverse drug reactions shall be immediately reported to the attending physician, charted in the clinical records, and described in Medication Error Report, and incident report if necessary, which is submitted to the State Health Department. Review of the Medication Omission/Withholding policy dated 7/2023 directed, in part, that all medications are to be administered as prescribed by the attending physician unless in the nurses professional judgement the medication(s) should be omitted/withheld. If the nurse makes the decision to omit/withhold medication(s) the nurse will notify the supervisor who will notify the MD and document in the clinical record. Nurses notes are to include the date, specific time, and pertinent details. Review of the Medication Refusal Policy dated 7/2023 directed, in part, that for medication refusals, the nurse will explain to the resident the possible consequences of medication refusal, and for non-competent confused residents, the nurse will go back and offer the medication again within an hour. The nursing supervisor will notify the MD once 3 consecutive doses of any medication is refused, will document the conversation with the MD in the clinical record and the nurse will properly document the medication refusal on the resident's electronic medical record. Review of the Medication Re-Order Procedure dated 7/2023 directed, in part, that the 3-11 shift nurse is responsible for re-ordering routine medications on a regular basis to ensure that a resident is never without an appropriate available supply of prescribed medications. Medications should be reordered when an eleven (11) day supply remains.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for eleven (11) of thirteen (13) residents (Resident #1, 2, 4, 5, 6, 7, 8, 9, 12, 13 and 14) reviewed for medication administration, the facility failed to ensure that diabetic, cardiac, anti-seizure, pain and behavioral medications were administered timely per physician's orders. These failures resulted in a finding of Immediate Jeopardy. The findings include:1. Resident #1 's diagnoses included epilepsy, type 2 diabetes mellitus with foot ulcers, osteomyelitis (an infection in the bone) and atrial fibrillation (irregular heartbeat).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), required moderate assistance for eating, substantial assistance for bed mobility and was dependent on staff for transfers.The Resident Care Plan (RCP) dated 12/19/2024 identified Resident #1 had diabetes mellitus, pain related to left first and fifth toe amputations and had the potential for seizure activity related to the diagnosis of epilepsy. Interventions included administering medications as ordered by the provider and monitoring and documenting side effects and effectiveness.Review of the facility census identified Resident #1 resided on the East unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #1 was ordered to receive the following medications: 01/01/2025 at 9:00 PM: Keppra (anti-seizure medication) 750 milligrams (mg) (twice daily medication) which was not signed off as administered until 10:23 PM by LPN #1. 03/02/2025 gabapentin (used to treat nerve pain) (2) 100 mg capsules (three times daily medication) related to polyneuropathy (damage to peripheral nerves causing symptoms such as numbness, burning pain and weakness) and the 8:00 AM and 12:00 PM doses were signed off as administered together at 11:23 AM by LPN #1. 03/02/2025 at 9:00 AM: Keppra 750 mg (twice daily medication), metformin (medication used to treat diabetes mellitus) 1000 mg (twice daily medication) and lisinopril (medication used to treat high blood pressure) 5 mg which were not signed off as administered until 11:23 AM by LPN #1. 03/10/2025: gabapentin (2) 100 mg capsules (three times daily medication) and the 8:00 AM and 12:00 PM doses were signed off as administered together at 11:00 AM by LPN #1. 03/10/2025 at 9:00 AM: Keppra 750 mg (twice daily medication), metformin 1000 mg (twice daily medication) and lisinopril 5 mg, which were not signed off as administered until 11:00 AM by LPN #1. 04/22/2025 at 4:00 PM: gabapentin (2) 100 mg capsules (three times daily medication), Keppra 750 mg (twice daily medication) and metformin 1000 mg (twice daily medication) which were not signed off as administered until 10:48 PM by RN #2. 04/22/2025 at 4:30 PM: Insulin Lispro (short-acting insulin) 2 units subcutaneously (under the skin) was ordered before meals and was not signed off as administered until 6:17 PM by RN #2. 05/21/2025 at 5:00 PM: metformin 1000mg (twice daily medication) which was not signed off as administered until 10:34 PM by RN #2. 05/21/2025 at 8:00 PM: gabapentin (2) 100 mg capsules (three times daily medication), Keppra 750 mg (twice daily medication) and Tylenol (pain reliever) 975 mg (three times daily medication) which were not signed off as administered until 10:35 PM by RN #2. Review of nurse's notes from 01/01/2025 through 05/22/2025 failed to identify that the nursing supervisor or the provider were notified of the late medication administrations for Resident #1.2. Resident #2's diagnoses included dementia without behavioral disturbances, seizures, hypertension (high blood pressure) and neoplasm (cancer) to the bone, soft tissue and skin.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), required setup assistance for eating and substantial assistance for bed mobility and transfers.The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #2 was at risk for alteration in comfort related to intracranial (inside the skull) injuries. Interventions included administering pain medication per physician's orders.Review of the facility census identified Resident #2 resided on the East unit.Review of the Medication Administration Audit Report for January 2025 identified Resident #2 was ordered to receive the following medications: 01/17/2025 at 8:00 AM: gabapentin 300 mg (twice daily medication) for pain which was not signed off as administered until 9:10 AM by LPN #1. 01/19/2025 at 8:00 AM: gabapentin 300 mg (twice daily medication) which was not signed off as administered until 9:22 AM by LPN #1. 01/20/2025 at 8:00 AM: gabapentin 300 mg (twice daily medication) which was not signed off as administered until 9:51 AM by LPN #1. 1/23/2025 at 4:00 PM: gabapentin 300 mg (twice daily medication) which was not signed off as administered until 5:18 PM by LPN #1.Review of nurse's notes from 01/17/2025 through 01/24/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #2.3. Resident #4's diagnoses included heart failure, chronic pain and type II diabetes mellitus.The Resident Care Plan (RCP) dated 12/23/2024 identified Resident #4 had diabetes mellitus, chronic pain, altered cardiac status and an implanted cardiac defibrillator (an implanted device under the skin that corrects life threatening heart rhythms). Interventions included administering medications as ordered by the physician and monitoring and documenting side effects and effectiveness.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #4 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating, bed mobility and transfers.Review of the facility census identified Resident #4 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #4 was ordered to receive the following medications: 01/12/2025 at 4:00 PM: methocarbamol (used to relieve pain) (2) 500 mg tablets (twice daily medication) for muscle spasms, coreg (used to treat heart failure and high blood pressure) (2) 6.25 mg tablets (twice daily medication) and gabapentin 300 mg (three times daily medication) for chronic pain which were not signed off as administered until 5:55 PM by LPN #1. 01/12/2025 at 4:30 PM: Insulin Lispro 4 units prior to meals which was not signed off as administered until 5:55 PM by LPN #1. 03/10/2025 at 12:00 PM: gabapentin 300 mg (three times daily medication) and Insulin Lispro 4 units before meals which were not signed off as administered until 2:39 PM by LPN #1. 04/10/2025 at 4:00 PM: methocarbamol (2) 500 mg tablets (twice daily medication), coreg (2) 6.25 mg tablets (twice daily medication), gabapentin 300 mg (three times daily medication) and hydrocodone-acetaminophen (narcotic pain medication) 5-325 mg (twice daily medication) for chronic pain syndrome which were not signed off as administered until 5:55 PM by LPN #1. 4/10/25 at 4:30 PM: Insulin Lispro 4 units prior to meals which was not signed off as administered until 6:31 PM by LPN #1. 05/17/2025 at 11:30 AM: Insulin Aspart (rapid acting insulin) 4 units which was not signed off as administered until 3:46 PM by LPN #1 05/17/2025 at 1:00 PM: gabapentin 300 mg (three times daily medication) which was not signed off as administered until 3:44 PM by LPN #1. 06/19/2025 at 4:00 PM: methocarbamol (2) 500 mg tablets (twice daily medication), coreg (2) 6.25 mg tablets (twice daily medication) and hydrocodone-acetaminophen 5-325 mg (twice daily medication) which were not signed off as administered until 8:18 PM by RN #2. Review of nurse's notes from 01/12/2025 through 06/20/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #4.Interview with Resident #4 on 6/24/25 at 3:05 PM identified that when LPN #1 worked, he/she did not receive ordered medications until hours after they were ordered, at times, his/her blood sugar was not obtained and, at times, he/she did not receive medications at all, which caused increased pain. Resident #4 identified he/she reported the medication issues to the ADNS about three (3) weeks prior but LPN #1 continued to work on the unit. Interview with the ADNS on 6/24/25 at 3:11 PM identified Resident #4 reported the medication issues to her when she accompanied Resident #4 on an outpatient appointment, but she did not report the allegation to the DNS, or to the State Agency and did not investigate the allegation. The ADNS identified she was new to her position and was unaware of the requirements for an allegation of neglect. 4. Resident #5's diagnoses included cardiomyopathy (disease of heart muscle), atrial fibrillation (irregular heart rhythm), congestive heart failure and pain. The Resident Care Plan (RCP) dated 10/29/2024 identified Resident #5 was at risk for altered cardiac status, had a cardiac pacemaker/defibrillator (implanted devices under the skin that help to regulate the heart), was taking an anticoagulant (blood thinner) related to atrial fibrillation and had chronic pain. Interventions included administering medications as ordered.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating, bed mobility and transfers.Review of the facility census identified Resident #5 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #5 was ordered to receive the following medications: 01/12/2025 at 4:00 PM: Eliquis (blood thinner) 5 mg (twice daily medication) for atrial fibrillation which was not signed off as administered until 6:11 PM by LPN #1. 04/17/2025 at 4:00 PM: Eliquis 5 mg (twice daily medication) which not signed off as administered until 10:44 PM by RN #2 04/17/2025 at 9:00 PM: Entresto (for congestive heart failure) 24-26 mg (twice daily medication), divalproex (anti-convulsant) 625 mg for mood disorder, risperidone (anti-psychotic) (2) 1 mg tablets and trazodone (for insomnia) 100 mg which were not signed off as administered until 11:01 PM by RN #2. 06/19/2025 at 4:00 PM: Eliquis 5 mg (twice daily medication) which was not signed off as administered until 10:19 PM by RN #2 06/19/2025 at 9:00 PM: Entresto 24-26 mg (twice daily medication), divalproex 625 mg, risperidone (2) 1 mg tablets and trazodone 100 mg which were not signed off as administered until 11:22 PM by RN #2. Review of nurse's notes from 01/12/2025 through 06/20/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #5.Interview with Resident #5 on 06/25/2025 at 9:27 AM identified there was a day during the prior week that a Nurses Aid (NA) administered his/her medications at 10:30 PM. Resident #5 could not describe the NA, but insisted the staff member was an NA and not a nurse. 5. Resident #6's diagnoses included type 2 diabetes mellitus with diabetic neuropathy (nerve damage caused by diabetes), heart failure, tachycardia (rapid heart rate) and chronic pain syndrome.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15) and was independent with eating, bed mobility and transfers.The Resident Care Plan (RCP) dated 10/31/2024 identified Resident #6 had diabetes mellitus, chronic pain syndrome and altered cardiovascular status. Interventions included administering medications as ordered and monitoring/documenting for side effects and effectiveness.Review of the facility census identified Resident #6 resided on both the East Unit and the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #6 was ordered to receive the following medications: 02/04/2025 at 3:00 PM: 1.5 tablets of trazodone 100 mg for agitation and poor sleep pattern which was not signed off as administered until 8:28 PM by LPN #1. 02/04/2025 at 4:00 PM: 2 capsules of gabapentin 300 mg (twice daily medication) for pain which was not signed off as administered until 8:27 PM by LPN #1. 02/04/2025 at 5:00 PM: bumex 1 mg (twice daily medication) for congestive heart failure which was not signed off as administered until 8:27 PM by LPN #1. 02/07/2025 at 3:00 PM: 1.5 tablets of trazodone 100 mg which was not signed off as administered until 8:42 PM by LPN #1. 02/07/2025 at 5:00 PM: bumex 1 mg (twice daily medication) which was not signed off as administered until 7:37 PM by LPN #1. 04/10/2025 at 8:00 AM: 2 capsules of gabapentin 300 mg (twice daily medication), Insulin Aspart 4 units with meals, metoprolol succinate (used to lower blood pressure and heart rate) 100 mg (twice daily medication) and bumex 1 mg (twice daily medication) which were not signed off as administered until 2:32 PM by LPN #1. 04/10/2025 at 12:00 PM: Insulin Aspart 4 units with meals which was not signed off as administered until 2:39 PM by LPN #1 (7 minutes after the 8:00 AM dose of Insulin Aspart was signed off as administered). 04/22/2025 at 4:00 PM: 2 capsules of gabapentin 300 mg (twice daily medication), metoprolol succinate 100 mg (twice daily medication) and bumex 1 mg (twice daily medication) which were not signed off as administered until 8:32 PM by RN #2. 06/19/2025 at 4:00 PM: metoprolol succinate 100 mg (twice daily medication) and bumex 1 mg (twice daily medication) which were not signed off as administered until 7:52 PM by RN #2. 06/19/2025 at 5:00 PM: 2 capsules of gabapentin 300 mg (twice daily medication) which was not signed off as administered until 7:54 PM by RN #2. Review of nurse's notes from 02/4/2025 through 06/20/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #6.Interview with Resident #6 on 06/25/2025 at 9:11 AM identified that when LPN #1 worked, he/she consistently received medications late in the shift and receiving medications late caused him/her increased pain to the lower back and feet. Resident #6 identified his/her family member often visited in the evening and would leave the room to find LPN #1 to administer the medications.6. Resident #7 's diagnoses included muscle spasms of the back, neuropathy, chronic pain and congestive heart failure.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required setup assistance for eating and was dependent on staff for bed mobility and transfers.The Resident Care Plan (RCP) dated 01/11/2025 identified Resident #7 had chronic pain and altered cardiac function. Interventions included administering medications as ordered, anticipating the need for pain relief and responding immediately to complaints of pain.Review of the facility census identified Resident #7 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #7 was ordered to receive the following medications: 01/01/2025 at 8:00 AM: hydralazine 10 mg (three times daily medication) for hypertension (high blood pressure), 2 tablets gabapentin 600 mg (three times daily medication) for spinal stenosis (when the space inside the backbone is too small which can put pressure on the spinal cord and nerves) and baclofen 10 mg (three times daily medication) for muscle spasms which were not signed off as administered until 9:27 AM by LPN #1. 03/10/2025 at 12:00 PM: baclofen 10 mg (three times daily medication) and 2 tablets gabapentin 600 mg (three times daily medication) which were not signed off as administered until 2:28 PM by LPN #1 03/10/2025 at 1:00 PM: 2 tablets of hydralazine 10 mg (three times daily medication) and tramadol (used to treat pain) 50 mg (three times daily medication) for chronic pain syndrome which were not signed off as administered until 2:28 PM by LPN #1. 04/17/2025 at 9:00 PM: 2 tablets of gabapentin 600 mg (three times daily medication), doxazosin (used to treat high blood pressure) 4 mg, baclofen 10 mg (three times daily medication), tramadol 50 mg (three times daily medication) and 2 tablets of hydralazine (three times daily medication) which were not signed off as administered until 11:07 PM by RN #2. 05/17/2025 at 1:00 PM: baclofen 10 mg (three times daily medication), 2 tablets of gabapentin (three times daily medication), tramadol 50 mg (three times daily medication) and 2 tablets of hydralazine 10 mg (three times daily medication) which were not signed off as administered until 3:56 PM by LPN #1. 06/19/2025 at 9:00 PM: gabapentin 600 mg (three times daily medication), doxazosin 4 mg, baclofen 10 mg (three times daily medication), tramadol 50 mg (three times daily medication) and 2 tablets of hydralazine which were not signed off as administered until 11:11 PM by RN #2.Interview with Resident #7 on 06/25/2025 at 9:28 AM identified his/her medications were consistently administered late when LPN #1 and RN #2 worked, causing him/her increased pain and anxiety. Resident #7 indicated when he/she complained to the staff, he/she would eventually receive the medications but indicated he/she was worried about residents who could not self-advocate. Resident #7 identified that on 06/19/2025 at 10:00 PM he/she rang the call bell because he/she had not seen RN #2 since the start of the shift and both him/her and the roommate (Resident #5) had not yet received medications. Resident #7 identified a NA then administered a cup of pills to Resident #5 but he/she (Resident #7) received no medication that night. Resident #7 identified he/she wrote a complaint and gave it to staff to deliver to administration regarding the incident, but no one followed up with him/her regarding the complaint.Review of the letter dated 06/21/2025 from Resident #7 on 06/26/2025 identified, in part, that on the night of 06/19/2025, his/her nurse (RN #2) appeared to be absent and a NA brought Resident #5 (roommate) his/her medications at the end of the shift but he/she (Resident #7) did not receive any medications that night.Interview with the Administrator on 06/25/2025 at 10:48 AM identified there was a letter under his office door when he arrived to the facility on [DATE]. He identified he was unaware of who delivered the letter and that the facility was looking into it and indicated the DNS was given the letter for follow up.Interview with the DNS on 06/25/2025 at 10:53 AM identified she placed a call to RN #2 on 06/25/2025. She identified that RN #2 worked as an NA at the facility prior to becoming an RN and some residents still thought RN #2 was an NA. The DNS further identified she had not interviewed any other staff who worked during the evening/night shift on 06/19/2025. The DNS identified she reviewed the Medication Administration Record (MAR) for Residents #5 and #7 which identified medications were signed off as administered late on 06/19/2025 and that the provider should have been notified but was not. The DNS identified that the allegation from Resident #7 should have been reported to the Administrator or herself immediately rather than staff sliding a letter under the Administrator's office door and the allegation should have been reported to the State Agency, fully investigated and followed up on timely. 7. Resident #8's diagnoses included hypertension (high blood pressure), heart failure, atrial fibrillation (irregular heart rhythm), pain of the joints and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #8 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15).The Resident Care Plan (RCP) dated 11/18/2024 identified Resident #8 had altered cardiovascular status, was on anticoagulant therapy related to atrial fibrillation and had the potential for pain related to a wedge compression fracture, scoliosis, osteoporosis and lower extremity edema. Interventions included administering medications per physician's orders and monitoring for side effects and effectiveness every shift.Review of the facility census identified Resident #8 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #8 was ordered to receive the following medications: 01/24/2025 at 8:00 PM: metoprolol succinate 100 mg (twice daily medication) for hypertension which was not signed off as administered until 1/25/25 at 3:19 AM by RN #2 01/24/2025 at 9:00 PM: Eliquis 2.5 mg (twice daily medication) for atrial fibrillation and acetaminophen (2) 500 mg tablets for pain to the joints which were not signed off as administered until 1/25/25 at 3:20 AM by RN #2 . 02/17/2025 at 8:00 AM: metoprolol succinate 100 mg (twice daily medication) and Eliquis 2.5 mg (twice daily medication), which were not signed off as administered until 4:56 PM by LPN #1. 04/10/2025 at 8:00 AM: lisinopril (used to treat high blood pressure) 5 mg, Eliquis 2.5 mg (twice daily medication), metoprolol succinate 100 mg (twice daily medication) and trazodone 12.5 mg for anxiety which were not signed off as administered until 2:18 PM by LPN #1. 04/22/2025 at 8:00 PM: metoprolol succinate 100 mg (twice daily medication), acetaminophen (2) 500 mg tablets, and Eliquis 2.5 mg (twice daily medication), which were not signed off as administered until 9:57 PM by RN #2. 05/09/2025 at 8:00 AM: lisinopril 5 mg, Eliquis 2.5 mg (twice daily medication), metoprolol succinate 100 mg (twice daily medication) and trazodone 12.5 mg which were not signed off as administered until 10:27 AM by LPN #1. Review of nurse's notes from 01/24/2025 through 05/10/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #8.Interview with Resident #8 on 06/26/2025 at 2:06 PM identified that one night (could not recall the date) he/she did not receive evening medications until after 10:00 PM, he/she was worried and indicated that when he/she did not receive pain medications timely he/she could not sleep due to pain in the feet/toes. Resident #8 presented a notebook where he/she had written, LPN #1 comes too late at 9:30 PM to 10:00 PM referring to when he/she received medications when LPN #1 worked on the unit. 8. Resident #9's diagnoses included chronic pain, contracture of muscle of the right and left lower leg and polyneuropathy (damage or disease affecting the peripheral nerves outside the brain and spinal cord).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #9 had intact cognition (Brief Interview for Mental Status (BIMS) score of 15), required substantial assistance for bed mobility and transfers and was independent with eating.The Resident Care Plan (RCP) dated 12/12/2024 identified Resident #9 was at risk for pain related to arthritis, polyneuropathy and muscle contractures of the right lower extremity and the left lower extremity. Interventions included administering medication per physician's orders, anticipating the need for pain relief and responding immediately to any complaint of pain.Review of the facility census identified Resident #9 resided on the South unit.Review of the Medication Administration Audit Report from January 2025 through June 2025 identified Resident #9 was ordered to receive the following medications: 01/11/2025 at 8:00 AM: baclofen 7.5 mg (twice daily medication) for cramps and spasms which was not signed off as administered until 9:43 AM by LPN #1. 01/12/2025 at 4:00 PM: baclofen 7.5 mg (twice daily medication) which was not signed off as administered until 7:45 PM by LPN #1 01/12/2025 at 5:00 PM: acetaminophen (2) 325 mg tablets (twice daily medication) for pain which was not signed off as administered until 7:45 PM by LPN #1. 04/10/2025 at 4:00 PM: baclofen 7.5 mg (twice daily medication) and acetaminophen (2) 325 mg tablets (twice daily medication) which were not signed off as administered until 6:37 PM by LPN #1. 04/17/2025 at 4:00 PM: baclofen 7.5 mg (twice daily medication) and acetaminophen (2) 325 mg tablets (twice daily medication) which were not not signed off as administered until 4/18/25 at 12:37 AM by RN #2. 05/17/2025 at 8:00 AM: baclofen 7.5 mg (twice daily medication) and acetaminophen (2) 325 mg tablets (twice daily medication) which were not signed off as administered until 10:18 AM by LPN #1. 06/19/2025 at 4:00 PM: baclofen 7.5 mg (twice daily medication) and acetaminophen (2) 325 mg tablets (twice daily medication) which were not signed off as administered until 7:16 PM by RN #2.Review of nurse's notes from 01/11/2025 through 06/20/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #12.Although attempted, an interview with Resident #9 was not obtained.9. Resident #12's diagnoses included Alzheimer's disease and chronic pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #12 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 0), required setup assistance for eating and transfers and supervision assistance for ambulation.The Resident Care Plan (RCP) dated 05/22/2025 identified Resident #12 had chronic pain. Interventions included administering medications as ordered, anticipating the need for pain relief and responding immediately to any complaints of pain.Review of the facility census identified Resident #12 resided on the [NAME] unit.Review of the Medication Administration Audit Report for June 2025 identified Resident #12 was ordered to receive the following medications: 06/10/2025 at 5:00 PM: gabapentin 100 mg (three times daily medication) for chronic pain which was not signed off as administered until 6:33 PM by RN #2. 06/13/2025 at 5:00 PM: gabapentin 100 mg (three times daily medication) which was not signed off as administered until 8:43 PM by RN #2. 06/18/2025 at 5:00 PM: gabapentin 100 mg (three times daily medication) which was not signed off as administered until 7:31 PM by RN #2.Review of nurse's notes from 06/10/2025 through 06/19/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #12.10. Resident #13's diagnoses included Alzheimer's disease, hypertension (high blood pressure), major depressive disorder and central pain syndrome (consistent moderate to severe neuropathic pain).The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #13 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 1) and required setup assistance for eating and transfers.The Resident Care Plan (RCP) dated 05/15/2025 identified Resident #13 was at risk for behaviors due to delirium (serious change in mental abilities that results in confusion and a lack of awareness of one's surroundings) and used antipsychotic medication for the treatment of major depressive disorder and anxiety disorder. Interventions included administering medications per physician's orders, observing for side effects and effectiveness each shift and reporting any negative signs and symptoms to the provider.Review of the facility census identified Resident #13 resided on the [NAME] unit.Review of the Medication Administration Audit Report for June 2025 identified Resident #13 was ordered to receive the following medications: 06/13/2025 at 5:00 PM: bupropion 150 mg daily for depression and 2 capsules of Depakote 125 mg daily for dementia with behavioral disturbances which were not signed off as administered until 7:18 PM by RN #2. 06/18/2025 at 5:00 PM: bupropion 150 mg daily and 2 capsules of Depakote 125 mg daily which were not signed off as administered until 7:42 PM by RN #2.Review of nurse's notes from 06/13/2025 through 06/19/2025 failed to identify that the nursing supervisor or the provider were notified of the late medication administrations for Resident #13.11. Resident #14's diagnoses included dementia with agitation and type 2 diabetes mellitus.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 had severely impaired cognition (Brief Interview for Mental Status (BIMS) score of 5), required setup assistance for eating, supervision assistance for bed mobility and was independent with transfers and ambulation.The Resident Care Plan (RCP) dated 05/15/2025 identified Resident #14 had diabetes mellitus and utilized psychotropic medications related to adjustment disorder with anxiety, depressed mood and dementia. Interventions included administering medications as ordered by the physician and monitoring for side effects and effectiveness every shift.Review of the Medication Administration Audit Report for June 2025 identified Resident #14 was ordered to receive the following medications: 06/03/2025 at 4:00 PM: metformin 500 mg (twice daily medication) for diabetic management, Depakote 125 mg (twice daily medication) for behaviors and mood management and trazodone 25 mg (twice daily medication) for agitation which were not signed off as administered until 5:49 PM by LPN #1. 06/13/2025 at 4:00 PM: metformin 500 mg (twice daily medications), Depakote 125 mg (twice daily medication) and trazodone 25 mg (twice daily medication) which were not signed off as administered until 6:17 PM by RN #2. 06/18/2025 at 4:00 PM: metformin 500 mg (twice daily medication), Depakote 125 mg (twice daily medication) and trazodone 25 mg (twice daily medication) which were not signed off as administered until 8:03 PM by RN #2.Review of nurse's notes from 06/03/2025 through 06/19/2025 failed to identify the nursing supervisor or the provider were notified of the late medication administrations for Resident #14. Interview with LPN #1 on 06/24/2025 at 12:10 PM identified there were times that she administered medications late and further identified she documented as she administered medications. She identified a heavy medication pass on day and evening shifts on both the East and South units but indicated she was not aware she needed to notify the nursing supervisor and call the provider for medications that were more than one (1) hour late. Interview with RN #1 (nursing supervisor) on 06/24/2025 at 12:23 PM identified licensed nurses and NA's complained about LPN #1 not beginning the medication pass until two (2) hours prior to the end of the shift. RN #1 identified that the East and South unit medication passes were heavy and LPN #1 did not appear to administer medications to all her assigned residents as she was frequently off the floor and often difficult to find. She identified she spoke with both the previous DNS and current DNS several times regarding LPN #1, but to her knowledge, the concerns regarding LPN #1 were left unaddressed.Interview with LPN #3 on 06/24/2025 at 1:36 PM identified she worked first shift four (4) to five (5) days per week, and residents complained about not receiving medications or waiting until after 10:00 PM to receive medications, during the evening prior, when LPN #1 and RN #2 worked. LPN #3 identified she worked alongside LPN #1 during the day shift on weekends, LPN #1 worked on the East unit and she (LPN #3) worked on the South unit and residents on the East unit consistently rang their call bells asking where their medications were. She indicated LPN #1 did not communicate times she would leave the floor and that she (LPN #3) had a difficult time locating her. LPN #3 identified she reported the concerns and resident complaints to the DNS, but LPN #1 continued to work and be absent from the units while on shift.Interview with the DNS on 06/24/2025 at 2:01 PM identified RN #1, LPN #3 and LPN

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 6 residents, (Resident #43) reviewed for abuse, the facility failed to thoroughly investigate an allegation of abuse, failed to remove the staff member from the schedule following the allegation, and once the allegation was substantiated by the State Agency again failed to remove the staff member from the schedule to ensure the residents were protected from abuse. These failures resulted in the finding of Immediate Jeopardy. The findings include: Resident #43's diagnoses included dementia, personality disorder, and hypertensive heart disease with heart failure. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, did not experience episodes of delusions, and required maximal assistance for his/her toileting hygiene and chair to bed and bed to chair transfers. The MDS further indicated that Resident #43 did not reject evaluations of care including ADL assistance and was always incontinent of urine. The Resident Care Plan (RCP) in effect on 1/3/25 identified Resident #43 experienced frequent episodes of incontinence of bladder with an intervention of an assist of 2 with toileting upon request. The RCP further identified he/she had a behavior problem of making accusatory statements towards staff. Interventions included explaining all procedures to him/her before starting and allowing him/her to adjust to the changes, monitoring behavior episodes to determine the underlying cause, and documenting the behavior and potential cause. The Resident Care Card in effect on 1/3/25 identified Resident #43 was to have 2 staff members present at all times when in his/her room including when performing medication passes, answering call lights, and performing bathing and toileting tasks. An observation and interview with Resident #43 on 3/18/25 at 11:43 AM identified that he/she was sitting in the hallway in a wheelchair, hands flailing, crying, verbalizing he/she was upset regarding a financial matter. The resident verbalized, in the presence of Licensed Practical Nurse (LPN) #8, he/she had been hurt by staff on multiple occasions, most recently by LPN #7. The Director of Nursing Services (DNS) was called by LPN #8 to come to the resident's room regarding the allegation of abuse. An interview with Resident #43 on 3/18/25 at 11:51 AM was conducted in the presence of the DNS by the surveyor. Resident #43 alleged a few weeks prior, while he/she was trying to get into bed from his/her wheelchair, LPN #7 reached over the back of the wheelchair and pushed him/her onto the bed in a non-sexual manner. Resident #43 further identified that he/she was alone in the room with LPN #7 and started yelling for help, at which point LPN #7 grabbed the phone out of his/her hand and threw it across the room. It was noted by Resident #43, that Nurse Aide (NA) #7 entered the room and assisted him/her into bed in order to provide incontinence care. Resident #43 stated he/she experienced great humiliation over the event and continued to be afraid of LPN #7, noting LPN #7 continued to come into his/her room to provide care after the alleged incident of abuse. The DNS identified he was aware of the allegation of abuse and stated he had completed an investigation and reported the incident to the State Agency (SA). An interview and review of the abuse documentation with the DNS on 3/19/25 at 7:51 AM identified a Reportable Event (RE) form dated 1/3/25 indicating Resident #43 alleged LPN #7, with help from NA #7, picked up the resident threw him/her into bed. Actions taken indicated LPN #7 and NA #7 were off of the schedule until the investigation was completed and would no longer provide routine care. Review of the RE failed to identify that the allegation of mistreatment had been reported to the SA. Although requested, the DNS failed to provide documentation of a thorough investigation or any investigation whatsoever, except for a summary that he had created indicating what had transpired on 1/3/25. The summary of events was typewritten, noted to be undated, unsigned, and lacked the alleged staff member's name. The investigation provided lacked any staff interviews, staff statements, an interview with Resident #43, any resident interviews who may have witnessed or overheard the incident, or an interview with the staff member (LPN #7) against whom the allegation was made. The DNS indicated that the summary provided was created by him following his conclusion to the investigation into Resident #43's allegation of abuse dated 1/3/25. The DNS stated that he would have to look for the sworn and signed statements by the staff as he was unable to locate the information, and he would have to reach out to Information Technology (IT) to obtain the creation date of the investigation summary that was provided to the surveyor. Further, the RE indicated that the immediate action taken by the facility was that LPN #7 would no longer deliver care to Resident #43 unless it was in an emergency. The DNS stated that once the investigation had been completed, he had proven that the allegation of abuse was unfounded because Resident #43 had a history of allegations against staff, which were noted in the Resident Care Plan. The DNS was unable to further explain how he had reached his conclusion other than based on Resident #43's history of allegations. Additionally, the DNS identified that LPN #7 was allowed to return to providing care to Resident #43 upon the conclusion of the investigation. Interview with the DNS and Administrator on 3/19/25 at 9:45 AM identified the summary provided by the DNS to the surveyor had not been created following the conclusion of the investigation of mistreatment as previously stated. The DNS indicated that when he realized he had not submitted the RE to the SA, he had become nervous and wrote up the summary on 3/18/25 based on his memory of the events on 1/3/25. Further, the DNS indicated the nursing note written by LPN #7 on 1/5/25, which stated Resident #43 alleged to be thrown into bed, and not pushed, invalidated the allegation as the DNS deduced LPN #7 was not strong enough to throw the resident, adding this made all the difference in the outcome of his investigation. On 3/19/25 at 10:30 AM the DNS stated that he was unable to locate any of the sworn statements from the investigation he indicated was conducted following the abuse allegation on 1/3/25. Interview with NA #7 on 3/19/25 at 10:54 AM identified that she had no recollection of any incident that occurred on 1/3/25 and that the DNS had never asked her about the incident or to write a statement for the investigation. Following the interview with NA #7 the DNS informed the surveyor he would have NA #7 write a statement to replace the one he indicated was written at the time of the incident on 1/3/25 but he was unable to locate. An interview and review of nursing progress notes with LPN #7 on 3/19/25 at 4:26 PM identified that Resident #43 refused to be assisted with incontinence care when he worked on the second shift (7:00 PM to 10:45 PM) and remained wet. LPN #7 stated he worked on third shift (10:45 PM to 7:30 AM) and indicated that Resident #43 again declined to be assisted with incontinence care and that was when LPN #7 informed the resident that he/she had to be changed. LPN #7 stated that he would not be held responsible for the development of a urinary tract infection or [pressure] sore for Resident #43, so he provided the incontinence care despite Resident #43's objections. When NA #7 assisted putting the resident back to bed with LPN #7 they began to provide the incontinence care, and that is when Resident #43 began crying and yelling for help. LPN #7 remarked that was when he removed the phone from the resident's hand and told Resident #43 he/she could call for help when he was done. LPN #7 indicated he removed the phone because he could not reposition the resident if he/she was holding onto the phone. On the advice of the DNS, to protect himself, LPN #7 indicated he wrote a late progress note on 1/5/25 at 6:30 AM (2 days after the incident). Further, the progress note documented that the resident drew blood from LPN #7 in the process of LPN #7 transferring him/her back to the bed and that Resident #43 screamed, yelled, scratched, and hit staff during the incontinence care. LPN #7 indicated that Resident #43 was always crying about everything Boo Hoo Hoo this and Boo Hoo Hoo that and no one wanted to work with him/her because he/she cried about everything. LPN #7 stated that although he had subsequently spoken to the DNS about the incident, he was never asked by the DNS to write a statement. In a follow up interview with the DNS and Administrator on 3/20/25 at 8:36 AM the DNS indicated he had not yet begun an investigation into the allegation from 1/3/25, per the facility policy, and following the 3/18/25 interview with Resident #43 and the surveyor. The DNS stated the reason he had not done so was that he wanted to confirm with the surveyor first, but did not specify what he wanted to confirm. An interview and review of NA #7's newly written and undated statement with the DNS on 3/20/25 at 2:14 PM identified Resident #43 was fighting back and needed redirection multiple times during the 1/3/25 incident. The DNS reiterated that because Resident #43 was not thrown on the bed [was pushed], the abuse was unfounded. The DNS was informed by the surveyor that the abuse had been investigated and had been substantiated through the investigative process, by the surveyor. The DNS indicated that he would redo his investigation. According to punch in and punch out records, LPN #7 had punched in on 3/24/25 at 11:00 PM and punched out on 3/25/25 at 7:30 AM. A review of the staffing schedules identified that LPN #7 had been assigned to Resident #43's unit. Despite informing the DNS on 3/20/25 at 2:14 PM that the allegation of abuse had been substantiated by the surveyor, and LPN #7 had admitted to providing care to the resident against his/her will, LPN #7 was allowed to return to the facility, scheduled to work on Resident #43's unit, and worked in the facility on 3/24/25 on the 11:00 PM to 7:30 AM shift. An interview on 3/25/25 at 11:03 AM with the DNS identified that residents have the right to refuse care. He further identified if a resident refuses care, staff should document the refusal and reapproach later. The DNS identified that forcing a resident to receive care they had refused fell under the category of abuse. Although the DNS indicated to the surveyor that he would begin an investigation on 3/20/25, he stated that he still had not read LPN #7's progress indicating Resident #43 had drawn blood, although the DNS summary written 3/18/24 did identify blood was drawn during the resistance of care and he indicated he needed to investigate the 1/3/25 incident more thoroughly. Subsequent to surveyor inquiry, LPN #7 was removed from the staff schedule. A review of LPN #7's punch card identified LPN #7 had access to Resident #43 on 62 different shifts for the time period of 1/4/24 through 3/19/25, and again on 1/24/25. Review of the facility's Reportable Events Policy identified that a Class B event, (state classification) including a complaint of resident abuse, should be reported to the State Department of Public Health by the Administrator or DNS within the required time frame. An investigation will be conducted by the facility after the discovery of an allegation of abuse. The police are to be notified if an assault or suspected assault has occurred. Review of the facility's Abuse Reporting Policy identified when an allegation of abuse is reported, the facility administrator or his/her designee will notify the following persons of the incident: Department of Public Health; Ombudsman; Resident Representative; Law Enforcement Officials; and Primary Physician. Allegations of abuse must be reported no less than 2 hours after the allegation is made. A completed copy of the Reportable Event Form and written statements from witnesses must be provided to the Administrator within 24 hours of the occurrence of said incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical records, facility documentation, facility policy, and interviews for 22 of 40 residents (Resident #3, Resident #9, Resident #12, Resident #18, Resident #27, Resident #31, Resident #33, Resident #42, Resident #45, Resident #49, Resident #56, Resident #59, Resident #61, Resident #63, Resident #67, Resident #68, Resident #69, Resident #72, Resident # 74, Resident #78, Resident #81, Resident #92) reviewed during a tour of the secured memory unit, the facility failed to ensure the 5 Rights of medication administration, and professional standards of practice, were adhered to during the administration of medications. These failures resulted in the finding of Immediate Jeopardy. The findings include: 1. Resident #3's diagnoses included severe protein calorie malnutrition, cerebral infarction, and anxiety disorder. A physician's order dated 12/18/24 directed to administer Clopidogrel Bisulfate (antiplatelet) 75 milligrams (mg) orally once a day, Escitalopram Oxalate (antidepressant) 20 mg orally one a day, Multivitamin (supplement) 1 tablet orally once a day, Vitamin B Complex (supplement) 1 capsule orally once a day, Vitamin C (supplement) 1 tablet orally once a day, Vitamin D (supplement) 1 tablet orally once a day. A physician's order dated 1/19/25 directed to administer Aspirin 81 milligrams (mg) chewable orally once a day. A physician's order dated 2/2/25 directed to administer Trazadone 50 mg (antidepressant) orally twice a day, a physician's order dated 3/16/25 directed to administer Bupropion HCL ER (antidepressant extended release) 150 mg orally twice a day. 2. Resident #9 diagnosis included Alzheimer's dementia, diabetes, and congestive heart failure. A physician's order dated 8/6/24 directed to administer Memantine HCL (Anti-Alzheimer's) 5 mg orally1 tablet twice a day. A physician's order dated 8/7/24 directed to administer Aspirin 81 mg chewable orally once a day, Furosemide 20 mg (diuretic) 1 tablet orally once a day hold if systolic blood pressure is less than 100, Metformin HCL (antidiabetic) 500 mg 1 tablet orally once a day, Multivitamin 1 tablet orally once a day, Polysaccharide iron complex (supplement) 150 mg 1 capsule orally once a day, Toprol XL (extended release for high blood pressure) 25 mg 1 tablet orally once a day. A physician's order dated 8/9/24 directed Midodrine HCL (elevates blood pressure) 5 mg 1 tablet orally twice a day. A physician's order dated 2/21/25 directed to administer Tylenol extra strength 500 mg 2 tablets orally twice a day, 3. Resident #12's diagnosis included Parkinson's disease, dementia and emphysema. A physician's order dated 6/3/24 directed to administer Amlodipine (lowers blood pressure) 2.5 mg 1 tablet orally once a day, Carb/Levo (Parkinson's) 25-100 mg 1 tablet orally three times a day, Polyethylene Glycol powder (constipation) 3350 1 tablet once a day, Rivastigmine dis (Alzheimer's/Parkinson's) 9.5/24 apply 1 patch once a day trans dermally, Alendronate (osteoporosis) 70 mg 1 tablet orally once a day, aspirin chewable 81 mg 1 tablet orally once a day, Calcium /D 600-400 mg (supplement) 1 tablet orally once a day, Memantine 5 mg 1 tablet orally once a day, Vitamin D 1000 international units (IU) 2 caps orally once a day, Acetaminophen (pain) 500 mg 2 tablets orally twice a day, Budes/[NAME] Aer( emphysema) 160-4.5 120 Inh 2 puffs orally twice a day, Celecoxib cp (anti-inflammatory) 100 mg 1 capsule twice a day, Entacapone (Parkinson's) 200 mg 1 tablet orally twice a day. 4. Resident #18 diagnosis included Alzheimer's dementia, diabetes, and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 10 mg 1 tablet once a day, Aspirin low 81 mg 1 tablet orally once a day, Escitalopram 10 mg 1 tablet orally once a day, Hydrochlorothiazide (lowers blood pressure) tablet 25mg 1 tablet orally once a day, Losartan (lowers blood pressure) 50 mg 1 tablet orally once a day, Acetaminophen 500 mg tab orally twice a day, Metformin 1000 mg 1 tablet twice a day, Metoprolol Tar (lowers blood pressure) 50 mg 1 tab twice a day, A physician's order dated 10/29/24 directed to administer Potassium Chloride (elevates potassium) Liquid 20 milliequivalent/15 milliliter (mEq/ml) 20 met orally twice a day. A physician's order dated 1/14/25 directed Lantus Solostar (antidiabetic) subcutaneous solutions pen injector 100 unit/ml inject 16 units subcutaneously once a day. A physician's order dated 3/6/25 directed to administer Atorvastatin Calcium (lowers cholesterol) 20 mg 1 tablet orally once a day. A physician's order dated 3/7/25 directed to administer Fenofibrate (lowers cholesterol) 145 mg 1 tablet once a day. 5. Resident # 27 diagnosis included Dementia, Diabetes, and Epilepsy. A physician's order dated 5/30/24 directed to check blood sugars before meals and at bedtime. A physician's order dated 6/3/24 directed to administer Levetiracetam tabs (antiseizure) 500 mg give 1 tablet orally twice a day, Lisinopril ( lowers blood pressure) 5 mg give 1 tablet orally once a day, Metformin tab 1000mg give 1 tablet orally twice a day, Metoprolol Tar 25mg tablet give 0.5 tablet orally twice a day, Risperidone (antipsychotic) 2 mg tabs Give 1 tablet orally twice a day, Insulin lisp injection 100/ml inject per sliding scale if blood sugar is 150 - 199 give 2 units, 200-249 give 3 units, 250-299 give 4 units, 300-349 give 5 units, 350-399 give 6 units, grated than 399 give 8 units and call the physician subcutaneously before meals and at bedtime. A physician's order dated 7/15/24 directed to administer Gabapentin (antiseizure) capsule 300 mg give 1 capsule orally three times a day. A physician's order dated 7/23/24 directed to administer Depakote(antiseizure) oral tablet delayed release 250 mg give 2 tablets orally once a day. A physician's order dated 9/17/24 directed to administer oyster shell (supplement) oral tablet 500 mg give 1 tablet orally once a day. A physician's order dated 9/28/24 directed to administer Celexa (antidepressant) oral tablet 20 mg give 30 mg orally once a day. A physician's order dated 10/16/24 directed Celebrex (non-steroidal anti-inflammatory) oral capsule 100 mg give 1 capsule orally twice a day. A physician's order dated 10/24/24 directed to administer Oxycodone HCL (opioid pain reliever) tablet 5 mg, give 5 mg orally three times a day. A physician's order dated 11/5/24 directed to administer Amantadine (Parkinson's like symptoms) 100 mg caps give 2 capsules orally twice a day. A physician's order dated 11/6/24 directed to administer Cholecalciferol (supplement)oral capsule 1.25 mg give 1 capsule orally once a day every 7 days. A physician' order dated 1/15/25 directed to administer Xifaxan (treatment for high ammonia levels) 550 mg tabs give 1 tablet orally twice a day. 6. Resident #31's diagnosis included heart failure, depression and dementia. A physician's order dated 7/4/24 directed to administer Amlodipine besylate tablet 10 mg give 1 tablet orally once a day, Cyanocobalamin (supplement) tablet 1000 micrograms (mcg) give 1 tablet orally once a day, Lipitor oral tablet 10 mg give 10 mg orally once a day, MiraLAX oral packet 17 grams (gm) give 1 packet orally once a day, Multiple vitamins with minerals give 1 tablet orally once a day, Senna (laxative) oral tablet give 8.6 mg orally once a day. A physician's order dated 7/11/24 directed to administer Ferrous sulfate (iron supplement) tablet 2 mg give 1 tablet orally once a day, Folic acid (supplement) oral tablet 1 mg give 1 tablet orally once a day. A physician's order dated 7/13/24 directed to administer Trelegy Ellipta (reduce bronchospasms in asthma/COPD) inhalation aerosol powder breath activated 200-62.5-25 mcg/act 1 puff inhale orally once a day. A physician's order dated 8/28/24 directed to administer Lubiprostone (constipation) oral capsule 24 mcg give 2 mcg orally twice a day. A physician's order dated 10/12/24 directed to administer Singulair (prevents asthma attacks) oral tablet 10mg give 1 tablet orally once a day. A physician's order dated 11/6/24 directed to administer Allegra allergy oral tablet give 180 mg orally once a day for allergies. A physician's order dated 12/19/24 directed to administer Escitalopram oxalate tablet 20 mg give 1 tablet orally once a day. A physician's order dated 1/20/25 directed to administer Prednisone (steroid) oral tablet 10 mg give 1 tablet orally once a day. A physician's order dated 2/3/25 directed to check blood glucose twice a day. A physician's order dated 2/13/25 directed to administer Lasix oral tablet 20 mg give 40 mg orally once a day. A physician's order dated 2/19/25 directed to check blood sugar before meals and at bedtime. A physician's order dated 2/23/25 directed to administer Gabapentin tab 600 mg give 1 tablet oral three times a day, Freestyle Libre 2 reader device apply 1 application trans dermally before meals and at bedtime. Novolog injection solution 100 unit/ml inject 4 units subcutaneously before meals and at bedtime, Novolog injection solution 100 unit/ml as per sliding scale if 150-199 give 4 units, 200-249 give 6 units, 250-299 give 8 units, 300-349 give 10 units, 350-399 give 12 units, 400-449 give 14 units, 450-499 give 16 units, 500 give 20 units and notify the provider before meals and at bedtime. A physician's order dated 2/24/25 directed to administer Metformin HCL oral tablet 500 mg Give 1 tablet orally twice a day. A physician's order dated 2/26/25 directed to administer Trazadone (antidepressant) HCL oral tablet 50 mg give 25 mg orally once a day. A physician's order dated 3/5/25 directed to administer Oxycodone HCL oral tablet 5 mg give 0.5 tablet orally twice a day. A physician's order dated 3/12/25 directed to administer Protonix (excessive stomach acid) oral tablet delayed release 40 mg give 1 tablet orally twice a day for 8 weeks. 7. Resident # 33's diagnosis included dementia, congestive heart failure and Parkinson's disease. A physician's order dated 12/18/24 directed to administer Carb/Levo 25mg/100 tab give 2 tablets orally three times a day, Gabapentin 300 mg capsules give 1 capsule orally three times a day. A physician's order dated 12/28/24 directed to administer pantoprazole 40 mg tablets give 1 tablet orally twice a day. A physician's order dated 12/19/24 directed to administer Sertraline 100 mg tabs give 1 tablet orally once a day, aspirin low tab 8 mg give 1 tablet orally once a day, Clopidogrel tab 75 mg give 1 tablet orally once a day, Seroquel oral tablet 25 mg give 1 tablet orally once a day, A physician's order dated 1/28/25 directed to administer Amlodipine tab 10 mg Give 1 tablet orally once a day, Lisinopril tab 40 mg give 1 tablet orally once a day, Carvedilol 6.25 mg tab give 2 tablets orally twice a day, A physician's order dated 1/30/25 directed to administer Lantus subcutaneous solution 100 units/ml inject 40 units subcutaneously once a day. A physician's order dated 2/13/25 directed to administer Primidone tab 50 mg Give 0.5 tablet orally twice a day. Trazadone 50 mg tabs give 25 mg orally twice a day. A physician's order dated 2/14/25 directed to administer Humalog Kwik pen subcutaneous solution 100units/ml inject 5 units subcutaneously before meals. A physician's order dated 2/28/25 directed to administer Isosorbide Mononitrate ER tablet extended release 24-hour 60 mg give 1 tablet orally once a day. A physician's order dated 3/16/25 directed to administer Insulin lisp injection 100/ml per sliding scales if blood sugar is 150-199 give 3 units if less than 70 notify the provider, 200-249 6 units, 250-299 9 units, 300-349 12 units 350-399 15 units, greater than 400 18 units and notify the physician before meals and at bedtime. A physician's order dated 3/24/25 directed to administer Hydralazine HCL 50 mg tablets give 1.5 tablets orally three times a day. 8. Resident # 42's diagnosis included dementia, anxiety and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 5 mg give 1 tablet orally once a day, fluticasone/vilanterol inhaler (steroid/bronchodilator for treatment of COPD) 100/25/60 1 puff inhale orally once a day, Divalproex (antiseizure) tab 250 mg DR give 250 mg orally twice a day, Guaifenesin (expectorant) tab 400 mg give 1 tab twice a day, omeprazole tab 20 mg give 1 tab twice a day, omeprazole tab 20 mg give 1 tablet orally twice a day. A physician's order dated 8/13/24 directed to administer Tylenol extra strength oral tablet 500 mg give 1000mg orally twice a day. A physician's order dated 3/2025 directed to administer Escitalopram 5 mg tablet give 20 mg orally once a day, 9. Resident # 45's diagnosis included dementia, diabetes and seizures. A physician's order dated 5/30/24 directed to monitor glucose with Freestyle Libre device check resting blood sugar before meals and at bedtime. A physician's order dated 1/18/25 directed to administer Aspirin low 81 mg give 1 tablet orally once a day, Calcium citrate tab 200 mg give 1 tablet orally once a day, Polyether glycol powder 3350 NF give 17(Gram) gm orally once a day, Primidone tab 50 mg give 1 tablet orally every 12 hours, Tab a vit tab give 1 tablet orally once a day, Tresiba Flex injection 100 unit inject 12 units subcutaneously once a day, Vitamin C 500 mg tabs give 1 tablet orally once a day, Lexapro oral tablet 5 mg give 1 tablet orally once a day, Novolog flex pen subcutaneous solution pen injector 100 unit/ml inject 4 units subcutaneously once a day, Tamsulosin 0.4 mg caps give 1 capsule orally twice a day. A physician's order dated 1/20/25 directed to administer Sodium Bicarbonate (antacid) oral tablet 650 mg give 1 tablet orally twice a day, Sodium chloride oral tablet 1 gm give 1 tablet orally twice a day. A physician's order dated 1/29/25 directed to administer Norvasc oral tablet 5 mg give 1 tablet orally once a day, Coreg oral tablet 12.5 mg give 12.5 mg orally twice a day hold for systolic blood pressure less than 100 or heart rate less than 55 and notify physician, Hydralazine HCL oral tablet give 15 mg orally three times a day. 10. Resident #49's diagnosis included dementia, diabetes, and chronic kidney disease. A physician's order dated 8/22/24 directed to administer Tetrahydrozoline-dextran-polyethylene glycol povidone (eye irritation) eye drops instill 2 drops in left eye twice a day, Preparation H (hemorrhoid relief) rectal suppository insert 1 suppository rectally twice a day. A physician's order dated 8/23/24 directed to administer Citalopram Hydrobromide oral tablet 10 mg give 1 tablet orally once a day, Cyanocobalamin tablet 1000mcg give 2 tablets orally once a day, Folic acid oral tablet 1 mg give 1 tablet orally once a day, Lidocaine HCL external patch 4 % apply to lower back topically once a day, Lisinopril oral tablet 2.5 mg give 1 tablet orally once a day hold for systolic blood pressure less than 90 or diastolic blood pressure less than 60 and notify the physician, Pravastatin sodium oral tablet 20 mg give 1 tablet orally once a day, PreserVision AREDS (supplement) 2 oral capsule with minerals give 1 tablet orally once a day, Vitamin D3 oral tablet 25 mcg give 1 tablet orally once a day. A physician's order dated 8/30/24 directed to administer Lasix oral tablet 20 mg give 1 tablet orally every Monday, Wednesday and Friday, Tylenol oral tablet 325 mg give 2 tablets twice a day. A physician's order dated 10/1/24 directed to administer Ferrous Sulfate oral tablet 325 mg give 325 mg orally one a day. A physician's order dated 2/6/25 directed to administer Eliquis oral tablet 5 mg give 1 tablet orally twice a day. 11. Resident # 56's diagnosis included Alzheimer's disease, anxiety and depression. A physician's order dated 6/3/24 directed to administer Tab a Vite tab give 1 tablet orally once a day, 12. Resident # 59's diagnosis included dementia, congestive heart failure and anxiety disorder. A physician's order dated 6/26/24 directed to administer Cyanocobalamin oral tablet 1000 mg give 1 tablet orally once a day, folic acid oral tablet 1 mg give 1 tablet orally once a day, Lactulose (laxative)oral solution 20 gm/30 ml give 30 ml orally once a day, MiraLAX oral packet 17 gm give 17 gm orally once a day, multivitamin oral tablet give 1 tablet orally once a day, Thiamine HCL oral tablet 100 mg give 1 tablet orally once a day. A physician's order dated 10/8/24 directed to administer Lasix oral tablet 20 mg give 1 tablet orally once a day. A physician's order dated 11/23/24 directed to administer Prozac (antidepressant) oral capsule 10 mg give 10 mg orally once a day. A physician's order dated 1/13/25 directed to administer Potassium chloride ER oral tablet 20 mEq give 1 tablet orally once a day. A physician's order dated 1/16/25 directed to administer Risperdal oral tablet 0.5 mg give 0.25 mg orally once a day. 13. Resident #61's diagnosis included Diabetes, Dementia and Cerebral infarction. A physician's order dated 5/28/24 directed to administer Gabapentin cap 100 mg give 1 capsule twice a day, Metoprolol Tar tablet 50 mg give 1 tablet orally twice a day. A physician's order dated 6/3/24 directed to administer Aspirin low tab 81 mg give 1 tablet once a day, Escitalopram 10 mg tabs give 1 tablet once a day, Ezetimibe (lowers cholesterol) tab 10 mg give 1 tab orally once a day, fluticasone vilanterol inhaler 200/25 60 inhaler 1 inhalation orally once a day, Oxybutynin tab 15 mg ER give 1 tablet orally once a day, Pantoprazole 40 mg tabs give 1 tablet orally once a day, Rosuvastatin (lowers lipids) tab 40 mg give 1 tablet orally once a day, Acidophilus (probiotic) oral capsule give 1 capsule orally once a day, Eliquis 2.5 mg tabs give 1 tablet orally twice a day, Metformin tab 1000mg give 1 tablet orally twice a day. A physician's order dated 9/26/24 directed to administer Cholestyramine (lowers cholesterol) powder 4 gm lite give 4 grams orally once a day. A physician's order dated 3/12/25 directed to administer Trulicity subcutaneous solution autoinjector 0.75 mg/0.5 ml inject 1 syringe subcutaneously once a day every Wednesday. Humalog Kwik pen subcutaneous solution pen injector 1unit/ml inject 2 units subcutaneously before meals. Fasting blood sugar check before meals and at bedtime. Humalog 100 units/ml Kwik pen 3ml inject as per sliding scale if blood sugar is 100-199 give 10 units call physician if glucose is less than 70, 200-400 give 15 units call physician if blood sugar is greater than 400 subcutaneously before meals and at bedtime. 14. Resident #63's diagnosis included Alzheimer's dementia, diabetes, and cerebral infarction. A physician's order dated 6/3/24 directed to administer Aspirin low tab 81 mg give 1 tablet orally once a day, Donepezil 10 mg tabs give 1 tablet orally once a day, Escitalopram 10gm tabs give 1 tablet orally once a day, Tab a Vite tab give 1 tablet once a day, Vitamin B1 tab 100mg give 2 tablets orally once a day, Midodrine tab 5 mg give 1 tablet orally twice a day, Reguloid (fiber) powder orange give 2 tablespoons orally twice a day. A physician's order dated 6/4/24 directed to administer Cholecalciferol oral tablet give 25 mcg orally once a day. A physician's order dated 8/20/24 directed to administer Acetaminophen oral tablet 325 mg give 2 tablets orally three times a day. A physician's order dated 12/6/24 directed to administer Tramadol HCL oral tablet 25 mg give 1 tablet orally twice a day. 15. Resident #67's diagnosis included dementia, hypothyroidism, and chronic kidney disease. A Physician's order dated 6/3/24 directed to administer Allopurinol (gout) tab 100 mg give 1 tablet orally once a day, Amlodipine tab 10 mg give 1 tablet orally once a day, Eliquis 2.5 mg tabs give 1 tablet orally twice a day, Hydralazine tab 25 mg give 1 tablet orally twice a day, Acetaminophen 500 mg tabs give 2 tablets orally three times a day. A physician's order dated 7/31/24 directed to administer Vitamin B12 oral tablet give 1000 mcg orally once a day. A physician's order dated 12/18/24 directed to administer Trazadone 50 mg tabs give 0.5 tablet orally twice a day. 16. Resident # 68's diagnosis included Alzheimer's dementia, depression and hyperkalemia. A physician's order dated 6/3/24 directed to administer Vitamin D 1000 IU caps give 1 capsule orally once a day, Amlodipine besylate tablet 10 mg give 1 tablet orally once a day, Lisinopril tab 40 mg give 1 tablet orally once a day. A physician's order dated 11/2/24 directed to administer Trazadone HCL oral tablet 50 mg give 25 mg orally three times a day. A physician's order dated 12/19/24 directed to administer Escitalopram oxalate oral tablet 20 mg give 1 tablet orally once a day. A physician's order dated 1/18/25 directed to administer Aspirin EC tablet delayed release 81 mg give 1 tablet orally once a day. 17. Resident # 69's diagnosis included dementia, psychotic disorder with delusions, and chronic kidney disorder. A physician's order dated 6/3/24 directed to administer Amlodipine tab 10 mg give 1 tablet orally once a day, Aspirin low 81 mg give 1 tablet orally once a day, Ondansetron (nausea and vomiting) tab 4 mg give 1 tablet orally once a day, Potassium chloride cap 10 mEq ER give 2 capsules once a day, Sertraline 100 mg tabs give 1 tablet orally once a day as part of 125 mg dose in am, Sertraline 25 mg tabs give 1 tablet once a day as part of 125 mg dose in am, Multivitamin with minerals oral tablet give 1 tablet orally once a day, Calcium carb 500 mg tab give 1 tablet orally twice a day, Vitamin C 500 mg tab give 2 tablets orally twice a day. 18. Resident #72's diagnosis included dementia, hypothyroidism, and anxiety disorder. A physician's order dated 6/3/24 directed to administer Famotidine 10 mg tabs give 2 tablets orally once a day, Valsartan tab 160 mg give 1 tablet orally once a day, Vitamin D 3 50000 IU caps give 1 capsule orally once a day, Hydralazine tab 10 mg Give 1 tablet orally three times a day, A physician's order dated 6/20/24 directed to administer Aspirin tablet 81 mg give 1 tablet orally once a day. A physician's order dated 3/4/25 directed to administer Sodium Chloride oral tablet 1 gm give 1 tablet orally twice a day. 19. Resident # 74's diagnosis included Alzheimer's dementia, hypokalemia, and hypothyroidism. A physician's order dated 6/3/24 directed to administer Escitalopram 10 mg tabs give 1 tablet orally once a day, Lisinopril 10 mg tabs give 1 tablet orally once a day, Memantine 5 mg tabs give 1 tablet orally twice a day. A physician's order dated 1/17/25 directed to administer Vitamin B 12 oral tablet 100 mcg give 1 tablet orally once a day. 20. Resident # 78's diagnosis included Alzheimer's Dementia, hypothyroidism, and anxiety disorder. A physician's order dated 6/3/24 directed to administer Docusate sodium cap 100 mg give 1 capsule orally twice a day, Meloxicam tab 15 mg give 1 tablet orally once a day, Potassium chloride solution 10% give 15 ml orally once a day, Acetaminophen 500 mg tabs give 2 tablets orally twice a day, genteal tear (dry eyes) solution instill 2 drops in left eye twice a day. A physician's order dated 7/16/24 directed to administer Lisinopril tablet 2.5 mg give 1 tablet orally once a day. A physician's order dated 1/24/25 directed to administer Multiple vitamins with minerals give 1 tablet orally once a day. A physician's order dated 3/16/25 directed to administer Combigan (glaucoma) 0.2-0.5% ophthalmic solution instill 1 drop in both eyes twice a day. 21. Resident # 81's diagnosis included dementia, anxiety and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 2.5 mg tabs give 1 tablet orally once a day, Atenolol 25 mg tabs give 0.5 tablet orally once a day, Memantine tab 10 mg give 1 tablet orally twice a day, Senna 8.6 mg tabs give 2 tablets orally once a day. 22. Resident #92's diagnosis included Paranoid schizophrenia, hypokalemia and anxiety disorder. A physician's order dated 6/19/24 directed to administer Amlodipine besylate oral tablet 5 mg give 1 tablet orally once a day. A physician's order dated 7/27/24 directed to administer Oyster shell calcium oral tablet 500mg give 1 tablet orally once a day. A physician's order dated 12/4/24 directed to administer Trazadone HCL oral tablet 50 mg give 0.5 tablet orally twice a day. Observations on 3/26/25 at 10:30 AM, identified Licensed Practical Nurse (LPN) #6 was having difficulty accessing Point Click Care (PCC) the electronic medical record system (EMAR). LPN #6 was heard to state I can't get into these computers, I don't know what is wrong with these computers, I have not been able to get into PCC all morning. I hate these computers, I wish we just went back to paper. Interview with LPN #6 on 3/26/25 at 10:30 AM identified she was unable to access PCC since the start of her shift at 7:00 AM. She stated she had tried 2 laptops and 2 desktop computers unsuccessfully. LPN #6 indicated she had administered medications to the 22 residents on her assignment, for the morning medication pass by memory, without the benefit of the use of a Medication Administration Record (MAR). (An MAR ensures the 5 rights of medication administration, right patient, right drug, right dose, right route, and right time). LPN #6 stated that she had failed to document any of the non-narcotic medications that she had administered by any alternate means of record keeping. LPN #6 was able to show a written record of each of the residents who received narcotics as narcotic medications required a signature in the narcotic book, on the proof of use sheet, that the medication had been signed out for a specific resident. Additionally, LPN #6 identified she had failed to notify a supervisor or the Assistant Director of Nursing (ADNS) when she was unable to access the EMAR or the software used for medication administration, PCC, because she wanted to get the medications passed and planned on documenting what she had given after the medication pass was completed. LPN #6 indicated that if any resident medications had changed since her last shift, she would have expected the off-going nurse to communicate this verbally, during a nurse-to-nurse report, for each of the residents who may have had changes. LPN # 6 further indicated that it was not an appropriate practice to administer medications to residents without utilizing an MAR, and that the policy was to call a supervisor when locked out of the EMAR and PCC. Interview on 3/26/25 at 11:00 AM with the Assistant Director of Nursing Services (ADNS) identified that she was not made aware LPN #6 was unable to access the EMAR or PCC and had not received any communication from LPN #6 to reset her password. The ADNS stated that LPN #6 had passed medications to 22 residents without the benefit of an MAR and should have contacted the supervisor or herself to reset her password. The ADNS identified it was inappropriate and against the policy to administer medications without the benefit of utilizing the MAR to ensure the 5 rights of medication administration were performed. The ADNS was unable to explain why LPN #6 would administer medications to 22 residents, by memory, without utilizing an MAR. Interview with the Corporate Regional Nurse, Registered Nurse (RN) #4 on 3/26/25 at 11:26 AM identified that the physician, Advanced Practice Registered Nurse (APRN), and responsible parties had been notified of LPN #6's inappropriate use of memory to administer medications to 22 residents, without the benefit of utilizing an MAR. Interview with APRN #1 on 3/26/25 at 12:22 PM identified she was made aware that 22 residents were administered medications by LPN #6, by memory, without the benefit of an MAR, and that she had reviewed all of the medications ordered for the affected residents under her care. APRN #1 stated that for the residents who required blood sugar monitoring, she had ordered blood sugar checks immediately and to continue per the established schedule. All affected residents were to have vital sign checks every shift for 24 hours to monitor their health status. APRN #1 additionally ordered labs to be checked for the residents who were receiving sodium chloride tablets and that she was to be notified of any abnormalities. Interview with APRN #2 on 3/26/25 at 12:30 PM identified that she was made aware that 22 resident's medications were administered without the benefit of an MAR, by memory, by LPN #6. APRN #2 identified she had just observed all of the residents under her care, would review those resident medications, and would determine if further monitoring would be required. Additionally, APRN #2 identified that she would review the vital signs and blood sugars for her residents and leave orders to be notified for any abnormalities. Review of the charting and documentation policy dated 6/2023 revised, in part, directed that documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record: Objective observations, medication administered, treatment or services performed. Review of the job description for a charge nurse, is that the LPN/RN is responsible for the overall operation and optimal quality of care for the residents on the assigned unit, follows all health, sanitary and infection control policies, and maintains established standards of practice set forth by the facility's administration and nursing policies and procedures. The direct supervisor is the RN supervisor. Qualifications included knowledge of nursing theory and practice including the administration of medications. According to the National Library of Medicine dated 9/4/23 Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical records, facility documentation, facility policy and interviews for 22 of 40 residents (Resident #3, Resident #9, Resident #12, Resident #18, Resident #27, Resident #31, Resident #33, Resident #42, Resident #45, Resident #49, Resident #56, Resident #59, Resident #61, Resident #63, Resident #67, Resident #68, Resident #69, Resident #72, Resident # 74, Resident #78, Resident #81, Resident #92) reviewed during a tour of the secured memory unit, the facility failed to ensure safe medication administration practices during the morning medication pass. These failures resulted in the finding of Immediate Jeopardy. Additionally, based on observations, interviews, review of the clinical record and facility policy for 1 of 3 sampled residents (Resident #52) reviewed for nutrition, the facility failed to conduct reweights according to the facility policy. The findings include: 1. a. Resident #3's diagnoses included severe protein calorie malnutrition, cerebral infarction, and anxiety disorder. A physician's order dated 12/18/24 directed to administer Clopidogrel Bisulfate (antiplatelet) 75 milligrams (mg) orally once a day, Escitalopram Oxalate (antidepressant) 20 mg orally one a day, Multivitamin (supplement) 1 tablet orally once a day, Vitamin B Complex (supplement) 1 capsule orally once a day, Vitamin C (supplement) 1 tablet orally once a day, Vitamin D (supplement) 1 tablet orally once a day. A physician's order dated 1/19/25 directed to administer Aspirin 81 milligrams (mg) chewable orally once a day. A physician's order dated 2/2/25 directed to administer Trazadone 50 mg (antidepressant) orally twice a day, a physician's order dated 3/16/25 directed to administer Bupropion HCL ER (antidepressant extended release) 150 mg orally twice a day. b. Resident #9 diagnosis included Alzheimer's dementia, diabetes, and congestive heart failure. A physician's order dated 8/6/24 directed to administer Memantine HCL (Anti-Alzheimer's) 5 mg orally1 tablet twice a day. A physician's order dated 8/7/24 directed to administer Aspirin 81 mg chewable orally once a day, Furosemide 20 mg (diuretic) 1 tablet orally once a day hold if systolic blood pressure is less than 100, Metformin HCL (antidiabetic) 500 mg 1 tablet orally once a day, Multivitamin 1 tablet orally once a day, Polysaccharide iron complex (supplement) 150 mg 1 capsule orally once a day, Toprol XL (extended release for high blood pressure) 25 mg 1 tablet orally once a day. A physician's order dated 8/9/24 directed Midodrine HCL (elevates blood pressure) 5 mg 1 tablet orally twice a day. A physician's order dated 2/21/25 directed to administer Tylenol extra strength 500 mg 2 tablets orally twice a day, c. Resident #12's diagnosis included Parkinson's disease, dementia and emphysema. A physician's order dated 6/3/24 directed to administer Amlodipine (lowers blood pressure) 2.5 mg 1 tablet orally once a day, Carb/Levo (Parkinson's) 25-100 mg 1 tablet orally three times a day, Polyethylene Glycol powder (constipation) 3350 1 tablet once a day, Rivastigmine dis (Alzheimer's/Parkinson's) 9.5/24 apply 1 patch once a day trans dermally, Alendronate (osteoporosis) 70 mg 1 tablet orally once a day, aspirin chewable 81 mg 1 tablet orally once a day, Calcium /D 600-400 mg (supplement) 1 tablet orally once a day, Memantine 5 mg 1 tablet orally once a day, Vitamin D 1000 international units (IU) 2 caps orally once a day, Acetaminophen (pain) 500 mg 2 tablets orally twice a day, Budes/[NAME] Aer( emphysema) 160-4.5 120 Inh 2 puffs orally twice a day, Celecoxib cp (anti-inflammatory) 100 mg 1 capsule twice a day, Entacapone (Parkinson's) 200 mg 1 tablet orally twice a day. d. Resident #18 diagnosis included Alzheimer's dementia, diabetes, and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 10 mg 1 tablet once a day, Aspirin low 81 mg 1 tablet orally once a day, Escitalopram 10 mg 1 tablet orally once a day, Hydrochlorothiazide (lowers blood pressure) tablet 25mg 1 tablet orally once a day, Losartan (lowers blood pressure) 50 mg 1 tablet orally once a day, Acetaminophen 500 mg tab orally twice a day, Metformin 1000 mg 1 tablet twice a day, Metoprolol Tar (lowers blood pressure) 50 mg 1 tab twice a day, A physician's order dated 10/29/24 directed to administer Potassium Chloride (elevates potassium) Liquid 20 milliequivalent/15 milliliter (meq/ml) 20 met orally twice a day. A physician's order dated 1/14/25 directed Lantus Solostar (antidiabetic) subcutaneous solutions pen injector 100 unit/ml inject 16 units subcutaneously once a day. A physician's order dated 3/6/25 directed to administer Atorvastatin Calcium (lowers cholesterol) 20 mg 1 tablet orally once a day. A physician's order dated 3/7/25 directed to administer Fenofibrate (lowers cholesterol) 145 mg 1 tablet once a day. e. Resident # 27 diagnosis included Dementia, Diabetes, and Epilepsy. A physician's order dated 5/30/24 directed to check blood sugars before meals and at bedtime. A physician's order dated 6/3/24 directed to administer Levetiracetam tabs (antiseizure) 500 mg give 1 tablet orally twice a day, Lisinopril ( lowers blood pressure) 5 mg give 1 tablet orally once a day, Metformin tab 1000mg give 1 tablet orally twice a day, Metoprolol Tar 25mg tablet give 0.5 tablet orally twice a day, Risperidone (antipsychotic) 2 mg tabs Give 1 tablet orally twice a day, Insulin lisp injection 100/ml inject per sliding scale if blood sugar is 150 - 199 give 2 units, 200-249 give 3 units, 250-299 give 4 units, 300-349 give 5 units, 350-399 give 6 units, grated than 399 give 8 units and call the physician subcutaneously before meals and at bedtime. A physician's order dated 7/15/24 directed to administer Gabapentin (antiseizure) capsule 300 mg give 1 capsule orally three times a day. A physician's order dated 7/23/24 directed to administer Depakote(antiseizure) oral tablet delayed release 250 mg give 2 tablets orally once a day. A physician's order dated 9/17/24 directed to administer oyster shell (supplement) oral tablet 500 mg give 1 tablet orally once a day. A physician's order dated 9/28/24 directed to administer Celexa (antidepressant) oral tablet 20 mg give 30 mg orally once a day. A physician's order dated 10/16/24 directed Celebrex (non-steroidal anti-inflammatory) oral capsule 100 mg give 1 capsule orally twice a day. A physician's order dated 10/24/24 directed to administer Oxycodone HCL (opioid pain reliever) tablet 5 mg, give 5 mg orally three times a day. A physician's order dated 11/5/24 directed to administer Amantadine (Parkinson's like symptoms) 100 mg caps give 2 capsules orally twice a day. A physician's order dated 11/6/24 directed to administer Cholecalciferol (supplement)oral capsule 1.25 mg give 1 capsule orally once a day every 7 days. A physician' order dated 1/15/25 directed to administer Xifaxan (treatment for high ammonia levels) 550 mg tabs give 1 tablet orally twice a day. f. Resident #31's diagnosis included heart failure, depression and dementia. A physician's order dated 7/4/24 directed to administer Amlodipine besylate tablet 10 mg give 1 tablet orally once a day, Cyanocobalamin (supplement) tablet 1000 micrograms (mcg) give 1 tablet orally once a day, Lipitor oral tablet 10 mg give 10 mg orally once a day, MiraLAX oral packet 17 grams (gm) give 1 packet orally once a day, Multiple vitamins with minerals give 1 tablet orally once a day, Senna (laxative) oral tablet give 8.6 mg orally once a day. A physician's order dated 7/11/24 directed to administer Ferrous sulfate (iron supplement) tablet 2 mg give 1 tablet orally once a day, Folic acid (supplement) oral tablet 1 mg give 1 tablet orally once a day. A physician's order dated 7/13/24 directed to administer Trelegy Ellipta (reduce bronchospasms in asthma/COPD) inhalation aerosol powder breath activated 200-62.5-25 mcg/act 1 puff inhale orally once a day. A physician's order dated 8/28/24 directed to administer Lubiprostone (constipation) oral capsule 24 mcg give 2 mcg orally twice a day. A physician's order dated 10/12/24 directed to administer Singulair (prevents asthma attacks) oral tablet 10mg give 1 tablet orally once a day. A physician's order dated 11/6/24 directed to administer Allegra allergy oral tablet give 180 mg orally once a day for allergies. A physician's order dated 12/19/24 directed to administer Escitalopram oxalate tablet 20 mg give 1 tablet orally once a day. A physician's order dated 1/20/25 directed to administer Prednisone (steroid) oral tablet 10 mg give 1 tablet orally once a day. A physician's order dated 2/3/25 directed to check blood glucose twice a day. A physician's order dated 2/13/25 directed to administer Lasix oral tablet 20 mg give 40 mg orally once a day. A physician's order dated 2/19/25 directed to check blood sugar before meals and at bedtime. A physician's order dated 2/23/25 directed to administer Gabapentin tab 600 mg give 1 tablet oral three times a day, Freestyle Libre 2 reader device apply 1 application trans dermally before meals and at bedtime. Novolog injection solution 100 unit/ml inject 4 units subcutaneously before meals and at bedtime, Novolog injection solution 100 unit/ml as per sliding scale if 150-199 give 4 units, 200-249 give 6 units, 250-299 give 8 units, 300-349 give 10 units, 350-399 give 12 units, 400-449 give 14 units, 450-499 give 16 units, 500 give 20 units and notify the provider before meals and at bedtime. A physician's order dated 2/24/25 directed to administer Metformin HCL oral tablet 500 mg Give 1 tablet orally twice a day. A physician's order dated 2/26/25 directed to administer Trazadone (antidepressant) HCL oral tablet 50 mg give 25 mg orally once a day. A physician's order dated 3/5/25 directed to administer Oxycodone HCL oral tablet 5 mg give 0.5 tablet orally twice a day. A physician's order dated 3/12/25 directed to administer Protonix (excessive stomach acid) oral tablet delayed release 40 mg give 1 tablet orally twice a day for 8 weeks. g. Resident # 33's diagnosis included dementia, congestive heart failure and Parkinson's disease. A physician's order dated 12/18/24 directed to administer Carb/Levo 25mg/100 tab give 2 tablets orally three times a day, Gabapentin 300 mg capsules give 1 capsule orally three times a day. A physician's order dated 12/28/24 directed to administer pantoprazole 40 mg tablets give 1 tablet orally twice a day. A physician's order dated 12/19/24 directed to administer Sertraline 100 mg tabs give 1 tablet orally once a day, aspirin low tab 8 mg give 1 tablet orally once a day, Clopidogrel tab 75 mg give 1 tablet orally once a day, Seroquel oral tablet 25 mg give 1 tablet orally once a day, A physician's order dated 1/28/25 directed to administer Amlodipine tab 10 mg Give 1 tablet orally once a day, Lisinopril tab 40 mg give 1 tablet orally once a day, Carvedilol 6.25 mg tab give 2 tablets orally twice a day, A physician's order dated 1/30/25 directed to administer Lantus subcutaneous solution 100 units/ml inject 40 units subcutaneously once a day. A physician's order dated 2/13/25 directed to administer Primidone tab 50 mg Give 0.5 tablet orally twice a day. Trazadone 50 mg tabs give 25 mg orally twice a day. A physician's order dated 2/14/25 directed to administer Humalog Kwik pen subcutaneous solution 100units/ml inject 5 units subcutaneously before meals. A physician's order dated 2/28/25 directed to administer Isosorbide Mononitrate ER tablet extended release 24-hour 60 mg give 1 tablet orally once a day. A physician's order dated 3/16/25 directed to administer Insulin lisp injection 100/ml per sliding scales if blood sugar is 150-199 give 3 units if less than 70 notify the provider, 200-249 6 units, 250-299 9 units, 300-349 12 units 350-399 15 units, greater than 400 18 units and notify the physician before meals and at bedtime. A physician's order dated 3/24/25 directed to administer Hydralazine HCL 50 mg tablets give 1.5 tablets orally three times a day. h. Resident # 42's diagnosis included dementia, anxiety and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 5 mg give 1 tablet orally once a day, fluticasone/vilanterol inhaler (steroid/bronchodilator for treatment of COPD) 100/25/60 1 puff inhale orally once a day, Divalproex (antiseizure) tab 250 mg DR give 250 mg orally twice a day, Guaifenesin (expectorant) tab 400 mg give 1 tab twice a day, omeprazole tab 20 mg give 1 tab twice a day, omeprazole tab 20 mg give 1 tablet orally twice a day. A physician's order dated 8/13/24 directed to administer Tylenol extra strength oral tablet 500 mg give 1000mg orally twice a day. A physician's order dated 3/2025 directed to administer Escitalopram 5 mg tablet give 20 mg orally once a day, i. Resident # 45's diagnosis included dementia, diabetes and seizures. A physician's order dated 5/30/24 directed to monitor glucose with Freestyle Libre device check resting blood sugar before meals and at bedtime. A physician's order dated 1/18/25 directed to administer Aspirin low 81 mg give 1 tablet orally once a day, Calcium citrate tab 200 mg give 1 tablet orally once a day, Polyether glycol powder 3350 NF give 17(Gram) gm orally once a day, Primidone tab 50 mg give 1 tablet orally every 12 hours, Tab a vit tab give 1 tablet orally once a day, Tresiba Flex injection 100 unit inject 12 units subcutaneously once a day, Vitamin C 500 mg tabs give 1 tablet orally once a day, Lexapro oral tablet 5 mg give 1 tablet orally once a day, Novolog flex pen subcutaneous solution pen injector 100 unit/ml inject 4 units subcutaneously once a day, Tamsulosin 0.4 mg caps give 1 capsule orally twice a day. A physician's order dated 1/20/25 directed to administer Sodium Bicarbonate (antacid) oral tablet 650 mg give 1 tablet orally twice a day, Sodium chloride oral tablet 1 gm give 1 tablet orally twice a day. A physician's order dated 1/29/25 directed to administer Norvasc oral tablet 5 mg give 1 tablet orally once a day, Coreg oral tablet 12.5 mg give 12.5 mg orally twice a day hold for systolic blood pressure less than 100 or heart rate less than 55 and notify physician, Hydralazine HCL oral tablet give 15 mg orally three times a day. j. Resident #49's diagnosis included dementia, diabetes, and chronic kidney disease. A physician's order dated 8/22/24 directed to administer Tetrahydrozoline-dextran-polyethylene glycol povidone (eye irritation) eye drops instill 2 drops in left eye twice a day, Preparation H (hemorrhoid relief) rectal suppository insert 1 suppository rectally twice a day. A physician's order dated 8/23/24 directed to administer Citalopram Hydrobromide oral tablet 10 mg give 1 tablet orally once a day, Cyanocobalamin tablet 1000mcg give 2 tablets orally once a day, Folic acid oral tablet 1 mg give 1 tablet orally once a day, Lidocaine HCL external patch 4 % apply to lower back topically once a day, Lisinopril oral tablet 2.5 mg give 1 tablet orally once a day hold for systolic blood pressure less than 90 or diastolic blood pressure less than 60 and notify the physician, Pravastatin sodium oral tablet 20 mg give 1 tablet orally once a day, PreserVision AREDS (supplement) 2 oral capsule with minerals give 1 tablet orally once a day, Vitamin D3 oral tablet 25 mcg give 1 tablet orally once a day. A physician's order dated 8/30/24 directed to administer Lasix oral tablet 20 mg give 1 tablet orally every Monday, Wednesday and Friday, Tylenol oral tablet 325 mg give 2 tablets twice a day. A physician's order dated 10/1/24 directed to administer Ferrous Sulfate oral tablet 325 mg give 325 mg orally one a day. A physician's order dated 2/6/25 directed to administer Eliquis oral tablet 5 mg give 1 tablet orally twice a day. k. Resident # 56's diagnosis included Alzheimer's disease, anxiety and depression. A physician's order dated 6/3/24 directed to administer Tab a Vite tab give 1 tablet orally once a day, l. Resident # 59's diagnosis included dementia, congestive heart failure and anxiety disorder. A physician's order dated 6/26/24 directed to administer Cyanocobalamin oral tablet 1000 mg give 1 tablet orally once a day, folic acid oral tablet 1 mg give 1 tablet orally once a day, Lactulose (laxative)oral solution 20 gm/30 ml give 30 ml orally once a day, MiraLAX oral packet 17 gm give 17 gm orally once a day, multivitamin oral tablet give 1 tablet orally once a day, Thiamine HCL oral tablet 100 mg give 1 tablet orally once a day. A physician's order dated 10/8/24 directed to administer Lasix oral tablet 20 mg give 1 tablet orally once a day. A physician's order dated 11/23/24 directed to administer Prozac (antidepressant) oral capsule 10 mg give 10 mg orally once a day. A physician's order dated 1/13/25 directed to administer Potassium chloride ER oral tablet 20 mEq give 1 tablet orally once a day. A physician's order dated 1/16/25 directed to administer Risperdal oral tablet 0.5 mg give 0.25 mg orally once a day. m. Resident #61's diagnosis included Diabetes, Dementia and Cerebral infarction. A physician's order dated 5/28/24 directed to administer Gabapentin cap 100 mg give 1 capsule twice a day, Metoprolol Tar tablet 50 mg give 1 tablet orally twice a day. A physician's order dated 6/3/24 directed to administer Aspirin low tab 81 mg give 1 tablet once a day, Escitalopram 10 mg tabs give 1 tablet once a day, Ezetimibe (lowers cholesterol) tab 10 mg give 1 tab orally once a day, fluticasone vilanterol inhaler 200/25 60 inhaler 1 inhalation orally once a day, Oxybutynin tab 15 mg ER give 1 tablet orally once a day, Pantoprazole 40 mg tabs give 1 tablet orally once a day, Rosuvastatin (lowers lipids) tab 40 mg give 1 tablet orally once a day, Acidophilus (probiotic) oral capsule give 1 capsule orally once a day, Eliquis 2.5 mg tabs give 1 tablet orally twice a day, Metformin tab 1000mg give 1 tablet orally twice a day. A physician's order dated 9/26/24 directed to administer Cholestyram (lowers cholesterol) powder 4 gm lite give 4 grams orally once a day. A physician's order dated 3/12/25 directed to administer Trulicity subcutaneous solution autoinjector 0.75 mg/0.5 ml inject 1 syringe subcutaneously once a day every Wednesday. Humalog Kwik pen subcutaneous solution pen injector 1unit/ml inject 2 units subcutaneously before meals. Fasting blood sugar check before meals and at bedtime. Humalog 100 units/ml Kwik pen 3ml inject as per sliding scale if blood sugar is 100-199 give 10 units call physician if glucose is less than 70, 200-400 give 15 units call physician if blood sugar is greater than 400 subcutaneously before meals and at bedtime. n. Resident #63's diagnosis included Alzheimer's dementia, diabetes, and cerebral infarction. A physician's order dated 6/3/24 directed to administer Aspirin low tab 81 mg give 1 tablet orally once a day, Donepezil 10 mg tabs give 1 tablet orally once a day, Escitalopram 10gm tabs give 1 tablet orally once a day, Tab a Vite tab give 1 tablet once a day, Vitamin B1 tab 100mg give 2 tablets orally once a day, Midodrine tab 5 mg give 1 tablet orally twice a day, Reguloid (fiber) powder orange give 2 tablespoons orally twice a day. A physician's order dated 6/4/24 directed to administer Cholecalciferol oral tablet give 25 mcg orally once a day. A physician's order dated 8/20/24 directed to administer Acetaminophen oral tablet 325 mg give 2 tablets orally three times a day. A physician's order dated 12/6/24 directed to administer Tramadol HCL oral tablet 25 mg give 1 tablet orally twice a day. o. Resident #67's diagnosis included dementia, hypothyroidism, and chronic kidney disease. A Physician's order dated 6/3/24 directed to administer Allopurinol (gout) tab 100 mg give 1 tablet orally once a day, Amlodipine tab 10 mg give 1 tablet orally once a day, Eliquis 2.5 mg tabs give 1 tablet orally twice a day, Hydralazine tab 25 mg give 1 tablet orally twice a day, Acetaminophen 500 mg tabs give 2 tablets orally three times a day. A physician's order dated 7/31/24 directed to administer Vitamin B12 oral tablet give 1000 mcg orally once a day. A physician's order dated 12/18/24 directed to administer Trazadone 50 mg tabs give 0.5 tablet orally twice a day. p. Resident # 68's diagnosis included Alzheimer's dementia, depression and hyperkalemia. A physician's order dated 6/3/24 directed to administer Vitamin D 1000 IU caps give 1 capsule orally once a day, Amlodipine besylate tablet 10 mg give 1 tablet orally once a day, Lisinopril tab 40 mg give 1 tablet orally once a day. A physician's order dated 11/2/24 directed to administer Trazadone HCL oral tablet 50 mg give 25 mg orally three times a day. A physician's order dated 12/19/24 directed to administer Escitalopram oxalate oral tablet 20 mg give 1 tablet orally once a day. A physician's order dated 1/18/25 directed to administer Aspirin EC tablet delayed release 81 mg give 1 tablet orally once a day. q. Resident # 69's diagnosis included dementia, psychotic disorder with delusions, and chronic kidney disorder. A physician's order dated 6/3/24 directed to administer Amlodipine tab 10 mg give 1 tablet orally once a day, Aspirin low 81 mg give 1 tablet orally once a day, Ondansetron (nausea and vomiting) tab 4 mg give 1 tablet orally once a day, Potassium chloride cap 10 mEq ER give 2 capsules once a day, Sertraline 100 mg tabs give 1 tablet orally once a day as part of 125 mg dose in am, Sertraline 25 mg tabs give 1 tablet once a day as part of 125 mg dose in am, Multivitamin with minerals oral tablet give 1 tablet orally once a day, Calcium carb 500 mg tab give 1 tablet orally twice a day, Vitamin C 500 mg tab give 2 tablets orally twice a day. r. Resident #72's diagnosis included dementia, hypothyroidism, and anxiety disorder. A physician's order dated 6/3/24 directed to administer Famotidine 10 mg tabs give 2 tablets orally once a day, Valsartan tab 160 mg give 1 tablet orally once a day, Vitamin D 3 50000 IU caps give 1 capsule orally once a day, Hydralazine tab 10 mg Give 1 tablet orally three times a day, A physician's order dated 6/20/24 directed to administer Aspirin tablet 81 mg give 1 tablet orally once a day. A physician's order dated 3/4/25 directed to administer Sodium Chloride oral tablet 1 gm give 1 tablet orally twice a day. s. Resident # 74's diagnosis included Alzheimer's dementia, hypokalemia, and hypothyroidism. A physician's order dated 6/3/24 directed to administer Escitalopram 10 mg tabs give 1 tablet orally once a day, Lisinopril 10 mg tabs give 1 tablet orally once a day, Memantine 5 mg tabs give 1 tablet orally twice a day. A physician's order dated 1/17/25 directed to administer Vitamin B 12 oral tablet 100 mcg give 1 tablet orally once a day. t. Resident # 78's diagnosis included Alzheimer's Dementia, hypothyroidism, and anxiety disorder. A physician's order dated 6/3/24 directed to administer Docusate sodium cap 100 mg give 1 capsule orally twice a day, Meloxicam tab 15 mg give 1 tablet orally once a day, Potassium chloride solution 10% give 15 ml orally once a day, Acetaminophen 500 mg tabs give 2 tablets orally twice a day, Genteal tear (dry eyes) solution instill 2 drops in left eye twice a day. A physician's order dated 7/16/24 directed to administer Lisinopril tablet 2.5 mg give 1 tablet orally once a day. A physician's order dated 1/24/25 directed to administer Multiple vitamins with minerals give 1 tablet orally once a day. A physician's order dated 3/16/25 directed to administer Combigan (glaucoma) 0.2-0.5% ophthalmic solution instill 1 drop in both eyes twice a day. u. Resident # 81's diagnosis included dementia, anxiety and depression. A physician's order dated 6/3/24 directed to administer Amlodipine 2.5 mg tabs give 1 tablet orally once a day, Atenolol 25 mg tabs give 0.5 tablet orally once a day, Memantine tab 10 mg give 1 tablet orally twice a day, Senna 8.6 mg tabs give 2 tablets orally once a day. v. Resident #92's diagnosis included Paranoid schizophrenia, hypokalemia and anxiety disorder. A physician's order dated 6/19/24 directed to administer Amlodipine besylate oral tablet 5 mg give 1 tablet orally once a day. A physician's order dated 7/27/24 directed to administer Oyster shell calcium oral tablet 500mg give 1 tablet orally once a day. A physician's order dated 12/4/24 directed to administer Trazadone HCL oral tablet 50 mg give 0.5 tablet orally twice a day. Observations on 3/26/25 at 10:30 AM, identified Licensed Practical Nurse (LPN) #6 was having difficulty accessing Point Click Care (PCC) the electronic medical record system (EMAR). LPN #6 was heard to state I can't get into these computers, I don't know what is wrong with these computers, I have not been able to get into PCC all morning. I hate these computers, I wish we just went back to paper. Interview with LPN #6 on 3/26/25 at 10:30AM identified she was unable to access PCC since the start of her shift at 7:00 AM. She stated she had tried 2 laptops and 2 desktop computers unsuccessfully. LPN #6 indicated she had administered medications to the 22 residents on her assignment, for the morning medication pass by memory, without the benefit of the use of a Medication Administration Record (MAR). (An MAR ensures the 5 rights of medication administration, right patient, right drug, right dose, right route, and right time). LPN #6 stated that she had failed to document any of the non-narcotic medications that she had administered by any alternate means of record keeping. LPN #6 was able to show a written record of each of the residents who received narcotics as narcotic medications required a signature in the narcotic book, on the proof of use sheet, that the medication had been signed out for a specific resident. Additionally, LPN #6 identified she had failed to notify a supervisor or the Assistant Director of Nursing (ADNS) when she was unable to access the EMAR or the software used for medication administration, PCC, because she wanted to get the medications passed and planned on documenting what she had given after the medication pass was completed. LPN #6 indicated that if any resident medications had changed, she would have expected the off-going nurse to communicate this verbally, during a nurse-to-nurse report, for the resident medications that changed . LPN #6 further indicated that it was not an appropriate practice to administer medications to residents without utilizing an MAR, and that the policy was to call a supervisor when locked out of the EMAR and PCC. Interview on 3/26/25 at 11:00 AM with the Assistant Director of Nursing Services (ADNS) identified that she was not made aware LPN #6 was unable to access the EMAR or PCC and had not received any communication from LPN #6 to reset her password. The ADNS stated that LPN #6 had passed medications to 22 residents without the benefit of an MAR and should have contacted the supervisor or herself to reset her password. The ADNS identified it was inappropriate and against the policy to administer medications without the benefit of utilizing the MAR to ensure the 5 rights of medication administration were performed. Further, the ADNS was unable to explain why LPN #6 would administer medications to 22 residents, by memory, without utilizing an MAR. Interview with the Corporate Regional Nurse, Registered Nurse (RN) #4 on 3/26/25 at 11:26 AM identified that the physician, Advanced Practice Registered Nurse (APRN), and responsible parties had been notified of LPN #6's inappropriate use of memory to administer medications to 22 residents without the benefit of utilizing an MAR. Interview with APRN #1 on 3/26/25 at 12:22 PM identified she was made aware that 22 residents were administered medications by LPN #6, by memory, without the benefit of an MAR, and that she had reviewed all of the medications ordered for the affected residents under her care. APRN #1 stated that for the residents who required blood sugar monitoring, she had ordered blood sugar checks immediately and to continue per the established schedule. All affected residents were to have vital sign checks every shift for 24 hours to monitor their health status. APRN #1 additionally ordered labs to be checked for the residents who were receiving sodium chloride tablets and that she was to be notified of any abnormalities. Interview with APRN #2 on 3/26/25 at 12:30 PM identified that she was made aware that 22 resident's medications were administered without the benefit of an MAR, by memory, by LPN #6. APRN #2 identified she had just observed all of the residents under her care, would review those resident medications, and would determine if further monitoring would be required. Additionally, APRN #2 identified that she would review the vital signs and blood sugars for her residents and leave orders to be notified for any abnormalities. Review of the policy Electronic Medication Administration Record (EMAR) revised 6/2023 directed the licensed nurse will read the physician order and complete the 5 checks, administer the medication as ordered and document the administration in the EMAR. Although requested, the facility failed to provide a policy for MAR utilization. 2. Resident #52 had a diagnosis that included dementia, anxiety, heart failure and chronic atrial fibrillation (an irregular and rapid heartrate resulting in poor blood flow). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #52 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment, required set up assistance for eating, maximum assistance for personal hygiene, and was dependent on toileting and supervision/touching assistance for bed mobility and transfers. The Resident Care Plan (RCP) dated 10/7/24 identified Resident #52 was at risk for alteration in cardiovascular status related to congestive heart failure (CHF) and atrial fibrillation (an irregular and rapid heartrate resulting in poor blood flow). Interventions included a diet consult as necessary, monitoring/documenting and reporting any changes in lung sounds on auscultation, edema, and changes in weight. A physician's order dated 10/21/24 directed to obtain weekly weights every Wednesday and notify the supervisor if the resident refused. Review of the Weights and Vitals Summary identified Resident #52's weights as: Date Weight (Lbs.) Discrepancy (Lbs.) 10/21/24 222.0 0 10/23/24 222.0 0 10/30/24 220.0 -2 11/6/24 220.8 +0.8 11/13/24 229.6 +8.8 11/18/24 228.6 -1 11/20/24 229.0 +1.6 11/27/24 230.0 +1 11/27/24 223.8 -6.2 12/4/24 223.2 -0.6 12/11/24 220.6 -2.6 12/18/24 228.0 +7.4 1/1/25 226.1 -2.1 1/8/25 225.2 -0.9 1/15/25 219.9 -5.3 1/22/25 226.0 &nbs[TRUNCATED]