**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the residents' right to be free from neglect for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11) out of eleven residents sampled related to seizure medication management and follow-up laboratory orders for seizure medication therapeutic levels. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on 2/27/25, except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. Review of Resident #1's nutrition note, dated 3/7/25 at 9:59 a.m. revealed, Res [Resident] readmitted to facility 3/6/25 s/p [status/post] 7d [day] hospitalization. New Gtube [gastrostomy tube] inserted however res eats 75-100% of meals by mouth and requests snacks frequently. Will d/c [discontinue] enteral feed as res is able to meet needs via po [by mouth] at this time. Flush tube w/ [with] 150cc H20 [water] q [every] shift to maintain patency. Review of Resident #1's progress note, dated 3/7/25 at 10:21 a.m., written by Staff A, Licensed Practical Nurse (LPN), revealed, This writer received order from NP [Nurse Practitioner] stating resident able to take medication by mouth if resident refuses then we may use PEG-Tube for medications; resident is currently eating meals w/o [without] issues or concerns. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/25 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses don not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisitions form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that's the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the ammonia level scheduled for 3/20/25 was not

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide competent physician services for the treatment and monitoring of seizure diagnoses for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven sampled residents. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on 2/27/25, except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/25 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses do not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisition form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that's the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the ammonia level scheduled for 3/20/25 was not completed and said it should have been rescheduled but was not. 4. Review of admission Records showed Resident #4 was admitted on [DATE] with diagnoses including other seizures. Review of Resident #4's care plan showed a focus area of seizure disorder, dated 8/27/24. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of Resident #4's orders revealed the following active orders: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium). Give 2 capsule by mouth every 8 hours related to other seizures. Dated 2/6/25. - CBC, CMP, Depakote, TSH, Ammonia Level. One time a day every 90 day(s) for hypertension, schizophrenia, cholecystitis. Dated 4/29/21. Review of Resident #4's provider note, dated 2/12/25, noted Depakote, check levels and ammonia levels. R[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure nursing staff were competent in caring for residents with seizure diagnoses to include laboratory monitoring process, following through with orders, processing consultations, and communications with physicians for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to Resident #1 and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on 2/27/25, except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. Review of Resident #1's nutrition note, dated 3/7/25 at 9:59 a.m. revealed, Res [Resident] readmitted to facility 3/6/25 s/p [status/post] 7d [day] hospitalization. New Gtube [gastrostomy tube] inserted however res eats 75-100% of meals by mouth and requests snacks frequently. Will d/c [discontinue] enteral feed as res is able to meet needs via po [by mouth] at this time. Flush tube w/ [with] 150cc H20 [water] q [every] shift to maintain patency. Review of Resident #1's progress note, dated 3/7/25 at 10:21 a.m., written by Staff A, Licensed Practical Nurse (LPN), revealed, This writer received order from NP [Nurse Practitioner] stating resident able to take medication by mouth if resident refuses then we may use PEG-Tube for medications; resident is currently eating meals w/o [without] issues or concerns. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/25 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses do not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisition form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that is the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the amm[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure laboratory orders were entered in the electronic medical record and electronic laboratory (lab) portal, labs were completed as ordered, and abnormal results were reported to providers in a timely manner for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on 2/27/25, except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/24 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses do not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisition form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that is the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed there was no documentation as to why the ammonia level scheduled for 3/20/25 was not completed and said it should have been rescheduled but was not. 4. Review of admission Records showed Resident #4 was admitted on [DATE] with diagnoses including other seizures. Review of Resident #4's care plan showed a focus area of seizure disorder, dated 8/27/24. Interventions included obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Review of Resident #4's orders revealed the following active orders: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 mg (Divalproex Sodium). Give 2 capsule by mouth every 8 hours related to other seizures. Dated 2/6/25. - CBC, CMP, Depakote, TSH, Ammonia Level. One time a day every 90 day(s) for hypertension, schizophrenia, cholecystitis. Dated 4/29/21. Review of Res[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure they effectively monitored adverse events to systematically identify, report, track, and analyze the data to prevent potential or serious harm to residents for ineffective management of health care services, and treatment for seizure medication management for eleven residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) out of eleven residents sampled. Serious harm occurred when Resident #1's seizure medication levels were not monitored, and neurology consultation was not obtained per the provider's request. Resident #1 experienced a seizure on 7/10/24, 9/28/24, 9/29/24, and 2/27/25. Resident #1 had to be transferred to a higher level of care as a result of the seizure suffered on 2/27/25. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and/or death to residents and resulted in the determination of Immediate Jeopardy on 4/16/2025. The findings of Immediate Jeopardy were determined to be removed on 4/17/2025 and the scope and severity was reduced to an E after verification of removal of immediacy of harm. Findings included: 1. Review of Resident #1's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with medical diagnoses of generalized idiopathic epilepsy and epileptic syndromes, not intractable, without status epilepticus, gastrostomy status as of 3/6/25, traumatic subdural hemorrhage with loss of consciousness, hydrocephalus, paraplegia, adult failure to thrive, protein-calorie malnutrition, anxiety disorder, major depressive disorder, lack of coordination, cognitive communication deficit, and Bell's palsy. Review of Resident #1's physician orders revealed the following: -Depakote (Valproic Acid) Sprinkles Oral Capsule delayed release 125 mg (milligrams), give one capsule by mouth two times a day for seizures, start date 5/23/24 and discontinued on 7/5/24. -Depakote Sprinkles Oral Capsule delayed release 125 mg, give one capsule by mouth three times a day for seizures, start date 7/6/24 and discontinued on 4/2/25. Review of Resident #1's July 2024 Medication Administration Record (MAR) revealed she received 125 mg of Depakote three times a day starting on 7/6/24. Review of Resident #1's laboratory (lab) results, dated 7/6/24, revealed her Valproic Acid levels were low at 10 microgram per milliliter (ug/ml). with a reference range of 50-100 ug/mL. Review of Resident #1's progress note, dated 7/7/24 at 8:13 p.m., revealed Hard copy labs called to ARNP (Advanced Registered Nurse Practitioner) . No new orders. Review of Resident #1's ARNP note, dated 7/7/24, revealed: CHIEF COMPLAINTS 7/7/24 fu [follow up] Visit She [Resident #1] has had some seizures in the past and had the recent seizure staff members reporting. Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. .ASSESSMENT AND PLAN .Seizure D-[NAME] [disorder] 7/7/24 Neurology consult, check medication levels .increased dose, depakote leve[sic] . Review of Resident #1's Progress note, dated 7/10/24 at 8:19 a.m., revealed Resident had a tonic-clonic seizure [a type of seizure with muscle stiffing followed by rhythmic jerking with a loss of consciousness] for 2 minutes. Resident was contracted and shaking the full time of the seizure. Resident is currently lying in bed. Dr. notified and waiting for a call back. Review of Resident #1's medical record did not reveal evidence the physician called back, or further attempts were made to contact the physician. Review of Resident #1's physician order revealed an order with a start date of 7/12/24, and an end date of 7/12/24 for Depakote Valproic Acid levels one time only for 1 day notify MD [Medical Doctor] of results. Review of Resident #1's lab results, dated 7/12/24, revealed Valproic Acid results were low (12 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid level on 7/12/24. Review of Resident #1's physician orders revealed an order, with a revision date of 7/15/24, a start date of 7/22/24, and an end date of 7/23/24, to recheck Valproic Acid level in one week. Review of Resident #1's progress note, dated 7/22/24 at 3:06 a.m., revealed Resident to have Valproic Acid level rechecked today Review of Resident #1's Treatment Administration Record (TAR) revealed the physician order for Resident to have Valproic Acid level rechecked today was signed off as completed on 7/22/24 at 3:06 a.m. Review of Resident #1's Lab Order History from the lab portal did not reveal a physician's order was in the lab portal for Valproic Acid to be drawn on 7/22/24. Review of Resident #1's medical record did not reveal evidence the Valproic Acid was drawn on 7/22/24 and reported to the physician. Review of Resident #1's Advanced Practice Registered Nurse (APRN) note, dated 9/13/24, revealed CHIEF COMPLAINTS 9/13/24-fu [follow up] Visit .Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's [activities of daily living] and assist with feeding in general. . ASSESSMENT AND PLAN .Seizure 9/13/24 Neurology Consult, check medications levels . Review of Resident #1's Physician note, dated 9/20/24 revealed CHIEF COMPLAINTS 9/20/24 fu Visit . Recently she had the seizure and medications were adjusted. Overall, she is very weak and feels like she is de-conditioned. She relies on staff to complete ADL's and assist with feeding in general. .Assessment and Plan .Seizure 9/20/24 Neurology consult, check medications levels . Review of Resident #1's medical record revealed no evidence she received neurology services. Review of Resident #1's progress note, dated 9/28/24 at 5:36 PM, revealed Resident had a seizure while lying in bed at 1730 [5:30PM]. Resident was laying on her side while seizure was occurring. Made sure of resident safety. Seizure was under 5 minutes long and not reoccurring. Resident is now alert and able to speak and move. No discomfort or pain noted. No injuries. MD [Medical Doctor] notified. New order placed for labs. Review of Resident #1's physician orders revealed, an order with an order date of 9/28/24,for Depakote level, Ammonia Level, Levetiracetam (Keppra), and Lacosamide level. There was no start date or end date on the physician order. Review of Resident #1's September 2024 MAR revealed the physician order for Depakote level, Ammonia level, Levetiracetam (Keppra), and Lacosamide level was not documented as completed. Review of Resident #1's Lab Order History on the laboratory portal did not reveal a physician order was placed on 9/28/24 for Depakote level, Ammonia Level, Levetiracetam (Keppra), or a Lacosamide level. Review of Resident #1's progress note, dated 9/29/24 at 7:30AM, revealed Seizure activity noted this am [morning] lasting approximately 3.5 minutes s/p [status post] snoring lasting about 2 minutes then aroused making eye contact with staff alert and orientated to self-97.2 [temperature]-76 [pulse]-20 [respiratory rate]-128/82 [blood pressure]-97% [oxygen saturations] R/A [room air]. Review of the medical record did not reveal the resident's physician was notified of the seizure. Review of Resident #1's lab report with a collection date of 9/30/24 at 5:09 p. m., revealed Valproic Acid was low (14 ug/mL) with a reference range of 50-100 ug/ml. Review of Resident #1's medical record did not reveal evidence the physician was notified of the low Valproic Acid (Depakote) lab results collected on 9/30/24. Review of Resident #1's physicians' orders, revealed an order, with a start date of 2/4/25 and an end date of 2/5/25, for a Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Depakote level, and Ammonia level, every night shift for one day. Review of Resident #1's lab results with a collection date of 2/5/25, revealed abnormal CBC, CMP and Depakote Level results for the following lab values: Glucose: Low (67 milligrams per deciliter (mg/dL)) with a reference range of 70-99 mg/dL BUN: High (24 mg/dL) with a reference range of 6-20 mg/dL BUN /Creatinine Ratio: High (38.6 mg/dL) with a reference range of 6.0-25.0 mg/dL Calcium: Low (3.4 mg/dL) with a reference range of 8.6-10.2 mg/dL RBC: Low (3.93 million per microliter (M/uL)) with a reference range of 4.1-10.9) M/uL HGB: Low (11. grams per deciliter (8g/dL)) with a reference range of 12.0-16.0 g/dL HCT: Low (35.9%) with a reference range of 37.0-47.0% Valproic Acid (Depakote): low (25 ug/mL) with a reference range of 50-100 ug/mL Review of Resident #1's Lab Order History on the laboratory portal revealed the Ammonia order, dated 2/5/25, had a status of collection pending, no results and there was no sample collection date. Review of Resident #1's medical record revealed no evidence the physician was notified of the abnormal lab results collected on 2/5/25. The medical record revealed no Ammonia levels were collected or physician communication related to the Ammonia level lab not being collected. An interview was conducted on 4/15/25 at 12:45 p.m. with the Director of Nursing (DON). She reviewed Resident #1's Lab Order History on the laboratory portal, and she said Collection pending, No Results means the labs were not drawn. Review of Resident #1's progress note, dated 2/27/25 at 9:18 a.m., revealed At approx. [approximately] 7:30am resident was having seizure activity. foaming[sic] at mouth and release of urine and feces noted. resident[sic] moved to[sic] onto her side until seizure ceased. Resident cont [continued] to be slow to wake and is nonverbal at this time. Resident has history of seizure activity. Family and MD aware. Review of Resident #1's change in condition, dated 2/27/25, revealed The change in condition .: Altered mental status The seizure was: New onset seizure activity, OR persistent seizure in someone with known intermittent seizure activity. Provider Notification and Feedback: .send to ER [emergency room] Review of Resident #1's hospital record revealed a physician note, dated 2/28/25, as: Impressions and Plan Breakthrough seizures due to noncompliance. The patient is currently unresponsive. This could be due to a postictal state, non-convulsive seizure activity or encephalopathy. I spoke to her [Resident #1's] nurse . at the nursing home . the patient has been refusing her medications. Yesterday she had a 4-minute convulsive seizure. Low Keppra level Low Depakote level but her dose of this medication may not be therapeutic. .Plan Prescribe telemetry Neurochecks every 2-4 hours Seizure precautions Lorazepam 2mg IV [intravenous] for convulsive seizure activity lasting more than 100 seconds IV Keppra IV Depakote IV Vimpat. She is also on oxcarbazepine that is not available in IV form, but the other AED's [anti-epileptic drugs] should be adequate. There is not yet clear how her refusal to take p.o. [by mouth] AEDs will get resolved. She may need a PEG [percutaneous endoscopic gastrostomy]. Review of Resident #1's hospital Gastrointestinal Physician note, dated 3/3/25, revealed: The patient presents with 50 yo [year old] f [female] who presented to the ed [emergency department] from her facility after a witnessed seizure. pt [patient] was also in the ed 2 days ago for glf [ground level fall]. I was asked to see the pt for a peg tube. Pt denies abdominal pain, n/v [nausea/vomiting] and dysphagia. Apparently, she frequently refuses to eat and take her medications due to her neurologic and psychiatric issues. Pt did not have issues swallowing during her vss [video swallow study]. per nursing if she is fed she will eat. She does pocket her food and requires verbal reminders. She has no abdominal pain, d/c [discomfort]. She has no gi [gastrointestinal] complaints. .plan Npo[nothing by mouth] after mn [midnight] Egd [esophagogastroduodenoscopy]/peg tomorrow. Review Resident #1's December 2024 through February 2025 Medication Administration Record (MAR) revealed she received 10 ml's of Keppra (100 mg/ml) by mouth twice a day every day for seizures except on 12/12/24 at 5:00 p.m. the documentation revealed 10. Review of the chart codes revealed 10=spit out meds. On 2/25/25 at 9:00 a.m. the documentation revealed 6 review of the chart codes revealed 6= hospitalized . On 2/26/25 at 9:00 a.m. the documentation revealed 2. Review of the chart codes revealed 2=drug refused. The February MAR review revealed Resident #1 received Depakote sprinkles 125 mg three times a day for seizures every day for the month of February until she was discharged on 2/27/25, except on 2/25/25 at 9:00 a.m. and 1:00 p.m., the documentation revealed Resident #1 was hospitalized . On 2/26/25 at 9:00 a.m. and 1:00 p.m. the documentation revealed Resident #1 refused the drug. Review of Resident #1's progress note, dated 3/6/25 at 2:12 p.m., revealed Resident returned to facility at approx. [approximately] 1;[sic]55pm via stretcher/ EMS [emergency medical services]. resident[sic] had no s/s [signs and symptoms] of distress noted .Resident has PEG tube in place and can eat by mouth. Jevity 1.2 @ 60 FWF [free water flush] 200ml q6 [every 6]. Resident can eat by mouth soft / bite sized. 1400 total in 24 hours. Two boxes a meal. Review of Resident #1's nutrition note, dated 3/7/25 at 9:59 a.m. revealed, Res [Resident] readmitted to facility 3/6/25 s/p [status/post] 7d [day] hospitalization. New Gtube [gastrostomy tube] inserted however res eats 75-100% of meals by mouth and requests snacks frequently. Will d/c [discontinue] enteral feed as res is able to meet needs via po [by mouth] at this time. Flush tube w/ [with] 150cc H20 [water] q [every] shift to maintain patency. Review of Resident #1's progress note, dated 3/7/25 at 10:21 a.m., written by Staff A, Licensed Practical Nurse (LPN), revealed, This writer received order from NP [Nurse Practitioner] stating resident able to take medication by mouth if resident refuses then we may use PEG-Tube for medications; resident is currently eating meals w/o [without] issues or concerns. An interview was conducted on 3/31/25 at 3:10 p.m. with the DON. The DON stated she did not assign a primary person to oversee the labs and review results. She said if labs were not critical staff would put the lab results in the providers' boxes for them to sign. If the labs were critical staff would call the provider to inform them about the critical lab results. The DON stated labs for seizure medications should be drawn every three months, but she does not know why some resident's labs were not being checked. She stated Resident #1's Depakote levels were being monitored by the psychiatric nurse practitioner. The DON stated she was aware that this was a system failure on the facility when it came to their lab process. She stated she would have expected her nurses to fax labs results to the doctor, put follow-up labs in to check the Depakote levels, and monitor the process. The DON stated Resident #1's labs from 9/30/2024 and 2/5/2025 were not signed off by the provider to show they reviewed the resident's lab results. She stated she thought Resident #1 had a neurology consultation while in the hospital, but the facility did not follow up to schedule a neurology appointment for Resident #1. The DON stated Resident #1's and Resident #2's labs were not done because the nurses were not transcribing the information from the orders to the lab reconciliation sheet and putting them in the lab book, so the tech knows which labs to draw for which residents. The DON stated it was her responsibility to ensure the resident's neurology consultation was followed up on. She stated there was a system failure because management did not have anyone assigned to pull labs, review lab results, and ensure all ordered labs were completed. The DON said their process was broken for following up with labs and completing documentation. An interview was conducted on 3/31/2025 at 3:50 p.m. with Resident #1's Psychiatry Physician Assistant (PA). The Psychiatry PA said he does not manage Resident #1's Depakote levels. If a resident is on Depakote for Seizures Psychiatry would not manage the medication; that would be managed by a resident's Primary Care Provider (PCP). An interview was conducted on 3/31/2025 at 4:20 p.m. with Resident #1's Advanced Practice Registered Nurse (APRN). The APRN said he does not monitor residents Depakote because it is managed by Psychiatry. He stated Depakote is not a medication he would prescribe a resident for seizures. He stated that he made a referral to have Resident #1 seen by a Neurologist in September 2024 and then again when Resident #1 came back from her most recent hospital stay (3/6/25), but he is not sure if the facility had followed up on his referral. He stated it is possible the low seizure medication labs could have been caught before the resident had her seizure if the facility had been managing her lab results and followed up with neurology. He stated residents who are on Keppra and Depakote medications for seizures should have labs drawn every three to six months to ensure the medication level are therapeutic for the resident's diagnosis. The APRN confirmed the facility should be doing the labs as ordered by the provider. For abnormal labs the facility should notify him the day the labs resulted and for critical labs the facility should get a hold of him. An interview was conducted on 4/15/25 at 1:50 p.m. with Staff B, LPN, she said she has worked at the facility on and off for four years and is very familiar with Resident #1. She said, Some years ago Resident #1 had a PEG tube for not eating, drinking, or taking her medications but she kept pulling the PEG tube out, so her family decided to just leave it out. She was doing well without it, eating, drinking, and taking her medications without any concerns. Staff B, LPN said for less than one day Resident #1 was not eating, drinking, or taking her medications and when she came in the next morning she had a huge gran-mal seizure, foaming at the mouth, lost control of her bowel and bladder, and then became post ictal (the period immediately following a seizure when the brain recovers, and the body returns to its normal state. During this phase, individuals may experience a range of symptoms, including confusion, drowsiness, headache, and cognitive difficulties.) Staff B, LPN said Resident #1's normal seizures are focal seizures, and she just stares, and they do not last long but this was a big one. Staff B, LPN said she called the physician and had Resident #1 sent to the hospital. Staff B, LPN said when Resident #1 returned the family must have agreed to a PEG tube again because she came back with a PEG tube but all we do is flush it in the morning with water. She said Resident #1 eats by mouth and takes her medications by mouth without any problems. She said since Resident #1 has returned from the hospital after her seizure she is still herself but not quite the same, we definitely fried some brain cells with that seizure. An interview was conducted with the Medical Director on 4/15/25 at 3:11 p.m., she said she was Resident #1's primary physician and she was familiar with the resident. She said, typically Resident #1's seizures are controlled, and she was on multiple seizure medications but, she did go to the hospital for a seizure. The Medical Director said when Resident #1 was admitted to the hospital for the seizure, her Keppra levels were low and her Depakote levels were not therapeutic, because she was not eating and was pocketing her medications [storing medications in her cheek]. She needed intravenous (IV) Keppra and IV Depakote because her levels were very low and it was an emergency. The Medical Director reviewed Resident #1's hospital notes and said Resident #1 had a PEG tube placed in the hospital because she was not eating or taking her medication, so it was life saving for her to have the PEG tube. The Medical Director said she did not remember the staff at the nursing home notifying her Resident #1 was not eating, drinking, or taking her medications. She said the nursing notes will reflect if they notified her or her APRN. The Medical Director said when labs are ordered her expectation is they are collected and once they have resulted the nurses should notify them immediately if any labs are critical. If they aren't critical then the nurses are supposed to put the results in the folder so she or her APRN can check them when they come in three to five times a week. The Medical Director said seizure medication levels should be drawn upon admission and every six months and if the seizure medication labs are abnormal the nursing staff should be notifying the Neurologist because she is not the Physician for the seizure medications, she is just supporting. The Medical Director said if there is an order for a neurology consultation then the facility should coordinate so the resident sees a Neurologist. The Medical Director said the residents had to go out to see a Neurologist because the facility did not have one coming to the facility. But there are transportation problems for bed ridden patients. An interview was conducted on 4/16/25 at 10:37 a.m. with Staff C, LPN she said she would get floated to take care of Resident #1. She said she works two double shifts a week the 3:00 p.m. to 11:00p.m. and 11:00 p.m. to 7:00 a.m. shift. She said before Resident #1 had her big seizure (2/27/25) she didn't have any problems giving her, her medications. She said the nurses knew you had to give her the medications in foods she liked, such as a milk shake. She said Resident #1 used to self-propel herself up and down the hallways yelling cheeseburger and asking for coffee. Staff C, LPN said now she is just not as spunky as she used to be before the seizure. Staff C, LPN said when she returned from the hospital she came back with a PEG tube. She said Resident #1 does not use the PEG tube, it's only there if she refuses to take her medications by mouth. Staff C, LPN said she does not have any issues with Resident #1 taking her medications or eating and drinking. An interview was conducted on 4/16/25 at 10:56 AM with Staff A, LPN 200 hall Unit Manager (UM) and the DON. Staff A, LPN, UM, said she has been a UM since the end of September and did not take over the 200 hall until the end of November. She said she knew Resident #1 for the most part, at the beginning, when Staff A, LPN, UM first started, she had only spit out her medications a couple of times and she was always eating so it was easy to give her medications. Only a day or two before her February seizure she was refusing her medications, But it wasn't long that she was refusing her meds before her seizure. The DON said it's their understanding she had a PEG tube a few years ago for failure to thrive but she had pulled it out and it was left out because she was eating and taking her medications by mouth without issues. The DON said when she came back from the hospital with the PEG tube, she worked with speech therapy and they were able to upgrade her diet right away and she continued to eat, drink, and take her medications without any problems. The DON said, she uses it for nothing and it is there just in case she does not take her medications. An interview was conducted on 4/16/25 at 11:02 a.m. with the DON. She said all the clinical nurses did not have access to the lab portal because they changed to the current lab in June 2024, We didn't push to get everyone access, there was just a push to get the system online. The DON said she had noticed for the past couple of months that lab orders had been cancelled. She said the facility just reordered the labs and didn't question why. The DON said the labs were just reordered and it was not really looked at as a system failure. A phone interview was conducted on 4/17/25 at 1:00 p.m. with Resident #1's Heath Care Proxy and family. They said they were informed Resident #1 went to the hospital in February for a seizure and when she was at the hospital, the hospital had called them and told them Resident #1 was pocketing her food, not drinking and not taking her medications that's why she had the seizure. The family gave the approval to put the PEG tube in and then they had a care plan meeting with the facility, and they were told Resident #1 was eating well and taking her medications by mouth and they were not using the PEG tube. A phone interview was conducted on 4/17/25 at 2:27 p.m. with the Regional Lab Supervisor. She said the Phlebotomist comes to the facility six days a week Monday through Saturday regardless if there are lab orders or not. She said they provide a Phlebotomist for STAT (immediately or without delay) labs as they need it. The Lab Supervisor said the expectation is the facility puts the lab order into the lab portal, print out the reacquisition form, and put the reacquisition form in the lab book. She said if the nurses do not have access to the lab portal, they can hand write the order on a blank reacquisition form, that the lab company provides, and put that in the lab book. The Phlebotomist will not know a lab needs to be drawn on a resident if there is not a reacquisition form in the lab book. The Lab Supervisor said if the nurse has put the order into the lab portal, but they did not print the requisition form and put it in the lab book then the Phlebotomist will not collect the lab and the order will sit in the portal and have a status of collection pending, no results. If the order is cancelled due to a collection error, then the lab will call the facility and have the nurse re-enter the order in the lab portal and print the reacquisition to put in the lab book so the Phlebotomist can redraw the labs the next day. Once the Phlebotomist has drawn the labs, they take the reacquisition forms with them and when they drop off the lab specimen someone from the lab makes sure the reacquisition was put into the portal because that is the only way the lab can print labels for the specimen. Once the test has resulted, then the result is uploaded into the lab portal and if there is a critical result the lab calls the facility. 2. Review of admission Records showed Resident #2 was admitted on [DATE] with diagnoses including unspecified injury of head and unspecified convulsions. Review of Resident #2's care plan showed a focus area of Seizure disorder. Interventions included: give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness and obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated and monitor labs and report sub therapeutic or toxic results to MD. Dated 10/4/17. Review of Resident #2's order showed the following: -Fasting comprehensive metabolic panel (CMP), lipids, complete blood count (CBC), Valproic Acid level, Ammonia level. One time a day every 4 months starting on the 1st for 1 day for hypertensive atherosclerotic cardiovascular disease (ASCVD), drug monitoring. Schedule routine weekday mornings. Dated 3/9/22. -Fasting CMP, Lipids, CBC, Valproic Acid level, Ammonia level. Every night shift for 1 day. Dated 12/1/24. -Divalproex Sodium HCL capsule delayed release 250 mg (Depakote). Give 250 mg by mouth at bedtime for seizure disorder related to unspecified convulsions. Dated 4/13/22. -Valproic Acid level. Dated 3/31/25. -Ammonia level. Dated 4/1/25. Review of lab results for Resident #2 showed Valproic Acid level and Ammonia level, dated 8/1/24. The Valproic Acid level was low at 23 ug/ml with a reference range of 50-100 ug/ml and the ammonia level was high at 69 ug/ml with a reference range of 11.0-35.0 ug/ml. There were no results found for the labs ordered to be drawn on 12/1/24. The 3/31/25 order for Valproic Acid level was not completed. The labs were reordered and drawn on 4/15/25 with a low result of <13 ug/ml with a reference range of 50-100 ug/ml. The Ammonia level drawn on 4/1/25 was high at 80 umoL/ml with a reference range of 18-72 umoL/ml. Review of Resident #2's progress notes showed no documentation a provider was notified of the abnormal Valproic Acid and Ammonia results on 8/1/24. Review of Resident #2's Lab Order History on the lab portal showed no orders were input in their system for labs to be drawn on 12/1/24. There was an order put in on 3/31/25 for a Valproic Acid level. Review of Resident #2's progress notes, dated 4/15/25, showed obtained orders to redraw Valproic Acid due to alb [albumin] stating uncollected lab and Lab tech out to get STAT Valproic Acid. An interview was conducted on 4/15/25 at 12:40 p.m. with the DON. She confirmed Resident #2 had a Valproic Acid level ordered on 3/31/25 that was not completed. She said they did not realize it was not done until 4/15/25. At 1:56 p.m. the DON reviewed Resident #2's medical record and confirmed there was an active order for labs every 4 months. She said the lab order was one that had fallen through the cracks and labs were not transcribed to the lab portal and lab reconciliation sheets. She confirmed the resident had labs in August 2024 and not again until 3/31/25. A follow-up interview was conducted on 4/17/25 at 5:15 p.m. with the DON. She said somehow Resident #2's lab was cancelled on 4/15/25 by the lab or the nurse. She said the unit manager (UM) had been given this to check on the homework sheet and they should have caught the fact the lab was not completed. 3. Review of admission Records showed Resident #8 was admitted on [DATE] with diagnoses including epilepsy. Review of Resident #8's physician orders revealed the following: -Levetiracetam (Keppra) Oral Tablet 500 mg. Give 3 tablet by mouth two times a day related to epilepsy. Dated 11/25/24. -Ammonia Level. Every night shift every Wednesday for 4 weeks. Dated 2/5/25. Review of Resident #8's lab results, dated 3/4/25, showed an Ammonia Level results of 118 umol/L (micromole per liter) with a reference range of 18-72 umol/L. This was indicated as a critical result. The lab showed the result was reported on 3/4/25 at 11:38 a.m. Review of Resident #8's progress notes showed no documentation a provider was notified on 3/4/25 of the critically high ammonia level. There was a progress note, dated 3/5/25 at 9:02 a.m.,. showing labs were sent to the Advanced Registered Nurse Practitioner. Review of Resident #8's Treatment Administration Record (TAR) showed the Ammonia level that was scheduled to be rechecked on 3/20/25 was documented as 9 indicating Other/See Nurse Notes. Review of progress notes revealed no nurses' note showing why the lab was not drawn. Review of Resident #8's lab results, dated 4/1/25, showed a Keppra level high at 49.5 ug/mL with a reference range of 6.0-46.0 ug/mL. An interview was conducted on 4/1/25 at 2:35 p.m. with the DON. She reviewed Resident #8's medical record and confirmed documentation showed the provider was not notified of the critical high ammonia level until the day after the results were received. She said her expectation would be the provider to be notified immediately of critical results. The DON confirmed [TRUNCATED]