**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and clinical record review the facility failed to provide adequate treatment and interventions to prevent the worsening of pressure ulcers for 1 resident (Resident #23) and failed to implement interventions timely for 2 of 4 residents reviewed (Resident #23, #15). Staff failed to apply the pressure-reducing boots for Resident #23 and failed to document or follow up on a new area for Resident #23 and #15. The facility reported a census of 65 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. 1. According to the Minimum Data Set (MDS) dated [DATE], Resident #23 was unable to participate in a Brief Interview for Mental Status (BIMS) assessment. He had severe memory problems, and impaired cognitive skills. The resident was totally dependent on staff for eating, toileting, dressing, rolling over, and transfers. Resident #23 was at risk for pressure injury and did not have any ulcers at the time of the assessment. His diagnoses included; deep venous thrombosis, neurogenic bladder, secondary Parkinsons, chronic embolism and thrombosis of deep veins of lower extremities, chronic kidney disease. The Care Plan for Resident #23, last revised on 8/7/24, showed that the resident was at risk for fluid volume depletion/excess edema, and was on diuretic therapy. Nursing was to monitor for edema. He had chronic pain related to arthritis and neuropathy in the bilateral lower extremities, nursing was to encourage and assist to position for comfort. The resident was at risk for skin breakdown related to impaired mobility, pain and use of compression stockings. Nursing was to assist with wearing heel protectors at all times and floating heels while in bed to prevent pressure sores. Staff were to observe skin and any wounds for changes such as redness, tenderness, drainage and to notify the physician. The Braden assessment dated [DATE] for Resident #23 documented he was at moderate risk for pressure related skin breakdown. On 6/2/25 at 12:44 PM, a Hospice Nurse Aide (HNA) attended to the resident and removed his stockings. The resident was not wearing edema-wear hose, the skin on his feet was tight and his lower extremities were swollen. On his left distal foot/heel area, there was an undated wound dressing patch. Medial to the patch was an uncovered, open red ulcer on his heel. On the 2nd and 3rd toes of the left foot there were small open blisters. The medial side of his right ankle contained an unblanchable red area. The HNA was not aware if any of these sores were new or if they were being treated. The documents titled: Skin Integrity Events revealed the following: a. On 3/18/25 at 1:39 PM, the resident had red moist area to bilateral groin and tips of toes dry and cracked. No other areas documented. b. On 5/6/25 at 6:55 PM, the resident had a new wound measuring 2 centimeter (cm) x 2 cm. It was intact, not open. The intervention implemented was skin prep and heel protectors. c. On 5/17/25 heels and toes not checked, no measurements. d. On 5/24/25 left heel 5 cm x 3.3 cm. brown center the medial aspect of skin injury tissue was black in color and 2 cm x 2 cm. the second and third toes 0.2 cm x 0.2 cm. A review of the clinical record revealed an order dated 4/14/23 that Resident #23 would wear bilateral heel protectors at all times. An on-going observation on 6/3/25 revealed the following: a. At 11:20, Staff pushed the resident to the lunch table. He was wearing gripper socks, no edema wear and no protective boots. b. At 1:30 PM, the resident was still in the wheel chair. It was tipped back slightly, he was sleeping. His feet were unsupported, dangling, not on the foot rest. c. At 3:30 PM, the resident was in the same position in front of the television in the dining area. His feet were dangling, not on foot pedals. His legs were swollen. d. At 4:20 PM, the resident was still in the wheel chair, in front of the television. His legs dangling. He was leaning forward in the chair with his head hanging down and reaching into the air for unseen items. A Nursing Note dated 6/4/25 at 2:25 PM, showed two new areas distal to the larger wound on the left heel that measured 0.5 cm x 0.5 cm. The area was pink surrounding the wound where the dressing tape maybe tearing the skin. The chart lacked mention of the new area on the right heel, and lacked documentation that the doctor or Hospice had been contacted regarding the new open wounds. On 6/5/25 at 8:02 AM, Staff O, Care Coordinator, provided wound treatment changes for Resident #23. The patch on his left heel was not dated and it was soaked with serosanguinous fluid. Staff O acknowledged that it was macerated. She said that the nurse on the previous day, had noticed that the wound was getting worse and they would contact hospice. The area on the left heel measured 2 cm. x 1.8 cm. in the center with two smaller areas nearby measuring 0.7 cm. x 0.6 and 0.5 cm. x 0.5 cm. When directed to the right heel, Staff O look at it and agreed that it was unblanchable, and it measured 2.6 cm x 1.4 cm. Staff O acknowledged that the protective boots must be on at all times. On 6/5/25 at 10:26 AM, Staff O CC said that she ordered a support board for the wheel chair for Resident #23. She said that his feet should not be dangling, and this was concerning for his chronic edema. Staff O said that the resident needed to be repositioned more often. According to a facility policy titled; Skin Integrity and Wound/Pressure Injury Prevention/Treatment/Observation and Documentation, dated June of 2020; preventative measures encourage repositioning, heel protectors. All nurses would be responsible for ensuring the Care Plan and interventions were updated and monitor to ensure interventions were carried out as planned. 2. According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #15 scored 10/15 on the Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The document revealed diagnoses of cerebrovascular accident/transient ischemic attack/stroke, Non-Alzheimer's dementia, coronary artery disease, and asthma/chronic obstructive pulmonary disease (COPD)/chronic lung disease. The assessment disclosed the resident required partial/moderate assistance for transfers, and independence with rolling left/right, and lying to/from sitting. The document revealed the resident was at risk for pressure ulcers/injury, did not have a pressure ulcer/injury, and no other skin problems or wounds. The document indicated the resident utilized skin and ulcer/injury treatments including pressure reducing devices for chair and bed. The resident did not receive Hospice services. The Electronic Medical Record (EMR) Skin Assessments for Resident #15 revealed the following: -On 1/19/25 red areas noted to the top of bilateral feet 1st digits. The resident denied pain. -On 1/23/25 tips of bilateral feet, 1st digits noted to have red areas. -On 1/30/25 tips of bilateral feet, 1st digits noted to have red areas. -On 2/6/25 red areas noted to bilateral feet 1st digits, the tip of them. -On 2/14/25 no concerns with feet. -On 2/20/25 red areas noted to bilateral feet, 1st digits. -On 2/28/25 no concerns with toes. -On 3/5/25 left foot, 1st digit noted to have a black area that measures approximately 1.2 cm in diameter. Right foot, 1st digit noted to have a scabbed area that measures approximately 0.5 cm in diameter. No drainage noted from either digit. Requested that the resident be seen by the wound nurse during rounds. Also a request had already been sent for a podiatry appointment. -On 3/6/25 left foot, 1st digit noted to have a black area that measures approximately 1.2 cm in diameter. Right foot, 1st digit noted to have a scabbed area that measures approximately 0.5 cm in diameter. No drainage noted from either digit. The Braden Scale, dated 1/11/25, revealed the resident was not at risk. The Progress Notes revealed on 2/24/25 a referral was generated for podiatry for the right foot; the 5th digit was long, loose, and fungal. The Progress Notes revealed notification to the physician with new orders on 3/6/25 for painting Betadine to scabbed areas on bilateral great toes twice daily until healed. Note on 3/6/25 also revealed referral to hospice services. Observed on 6/2/2025 at 12:27 PM Resident #15 seated in her recliner with a blanket cradle tent at the foot of the bed. On 6/2/25 at 12:27 PM Resident #15's daughter stated the resident had pressure areas on her toes that were now healing. The family member stated the resident has a preference for having several blankets, and believed the blankets were applying pressure to her toes. The daughter stated the staff were now getting the resident up into her recliner more and the resident has a tent that keeps the blankets off of her toes. On 6/4/25 at 2:50 PM Staff J, Registered Nurse (RN)/Care Coordinator (CC) revealed she was not aware of the resident's skin condition until 3/5/25. Staff J stated when there was a change in skin condition the Care Coordinator and/or the physician should be notified. The staff stated it would have been acceptable to use a fax notification as it was not an emergency. Staff J stated she did not know what stage the wound was when she was notified as she did not stage the wound. On 6/4/25 at 3:32 PM Staff B, Director of Nursing (DON) stated the Care Coordinator should have been aware of the reddened toes either by reviewing the Skin Assessments or by notification from the nurse completing the assessment. On 6/5/25 at 9:35 AM the Administrator stated she expected if toes were reddened there would have been some intervention(s) put into place. The facility Skin Integrity and Wound/Pressure Injury Prevention/Treatment/Observation and Documentation Policy, dated 6/20, revealed all team members were responsible for preventing, caring and providing treatment for skin integrity issues. The document disclosed all impaired skin integrity concerns/skin care the physician should be notified immediately and documented. The document further revealed all nurses were responsible for monitoring for changes in condition, implementing interventions, and updating the Care Plan to prevent skin breakdown.

Based on observations, clinical record review, staff interviews, and policy review the facility failed to transfer a resident with a gait belt and the resident fell resulting in an injury for 1 of 10 residents (Resident #1) reviewed for falls and safe transfers. The facility reported a census of 67 residents. Findings include: The Minimum Data Set (MDS) assessment of Resident #1 dated 7/2/24 reflected the Brief Interview for Mental Status (BIMS) score of 14/15, indicating intact cognition. The resident required partial/moderate assistance for transfers, ambulation, and lower body dressing. In the past 7 days of the assessment period the resident used a walker and wheelchair. During the previous 5 days of the assessment period Resident #1 received scheduled pain medication and as needed (PRN) pain medication. The resident was frequently incontinent of bladder and occasional incontinence of bowel. The resident had diagnoses of heart failure and renal insufficiency. The document further revealed the resident took an anticoagulant medication. Resident #1's Care Plan had an identified problem area of risk for falls related to incontinence, need for staff assistance for transfers, pain and weakness. Approaches for staff to utilize included ensuring call light and frequently needed items were within reach, and placement of the lift recliner remote in the side pocket. Resident #1's pocket care plan at the time of the fall reflected the resident required staff assist x1 for activities of daily living (ADLs), and transfers with assistance x1. The Care Plan also identified the resident at risk for complications related to anticoagulant (blood thinner) therapy. It directed staff to assess for episodes of excessive bleeding/bruising and to notify the physician. The Active Orders for Resident #1 revealed the resident was on warfarin (blood thinner) 3mg oral every day. The email dated 7/24/24 to the staff of Resident #1's cottage, nursing department, and Staff G, Registered Nurse (RN), Care Coordinator from the therapy department provided instructions to staff that the resident required assistance of 1 staff for ambulation with a front wheeled walker and left (L) knee brace to and from the bathroom (room only). The electronic health record (EHR) revealed on 8/13/24 at 11:02 AM Staff G, RN, Care Coordinator, responded to a nurse stat call. The document revealed Resident #1 was seated on the floor with her backside to the toilet, legs in front of her, and a laceration to the back of her head. Staff H, Certified Nursing Assistant (CNA), was seated on the floor next to the resident. The document revealed the resident was responding at baseline; however, due to the resident taking an anticoagulant medication was sent to the emergency room via 911 services and admitted to the hospital. The Event Report document within the EHR dated 8/13/24 at 11:34 AM revealed Resident #1 sustained a ground level fall in the bathroom. The document indicated the resident had no complaints of pain post fall and sustained a laceration to the back of the head. Assessment of Resident #1 included vitals, range of motion, neurological check, facial muscle movement, upper extremity movements/grasps, lower extremity range of motion, pupil size/response/shape, and speech. The document revealed the resident's walker was in the bathroom, and the resident was wearing tennis shoes. The document indicated the primary care provider was called and a phone order was received for sending the resident to the hospital. The resident's son and daughter were called and notified of the fall, and the resident was transferred to the hospital. Resident #1's hospital record dated 8/13/24 to 8/16/24 revealed diagnoses of intraventricular hemorrhage, scalp laceration and closed head injury without loss of consciousness. An observation on 9/20/24 at 12:07 PM revealed Staff A, CNA, utilized an EZ Way Lift (weight bearing mechanical lift) for transferring Resident #1 from the wheelchair (w/c) in her bedroom to the bathroom/toilet and from the toilet to the resident's recliner. On 9/20/24 at 10:57 AM Staff I, Physical Therapist Assistant (PTA) stated Resident #1 prior to the fall on 8/13/24 required minimum to moderate assistance for sit to stand sequence, and once standing the resident required contact guard assist for ambulation using a front wheeled walker (FWW). Staff I stated the cottage staff were instructed to ambulate the resident using a FWW and L knee brace for bathroom/bedroom distances. The staff stated the resident had decreased compliance with use of the knee brace before the fall. Staff I stated staff should have had at least 1 hand on Resident #1 at all times. Staff I stated the use of gait belt is a facility requirement for all transfers. The staff stated since returning from the hospital, therapy had assessed the resident and recommended the use of an EZ Way Lift for all transfers as the resident was no longer safe for stand pivot transfers or ambulation due to knee pain and crepitus. Staff stated an email was sent to the cottage staff in July with instructions for room distance ambulation with the resident. On 9/20/24 at 12:15 PM Staff A stated prior to the fall in August, Resident #1 was able to ambulate to the bathroom with a gait belt and FWW. The staff stated a gait belt was required for all transfers. On 9/20/24 at 12:24 PM Resident #1 stated she did fall in the bathroom and cut the back of her head. The resident stated her feet just started sliding and she fell. The resident stated she did not like to wear her knee brace and was not wearing a gait belt at the time of the fall. On 9/20/24 at 12:43 PM Staff G, RN, Care Coordinator, stated on 8/13/24 she assessed Resident #1 post fall. The staff stated the resident did not have a gait belt or the knee brace on. Staff G stated the resident had a laceration on the back of her head, was conscious, and at baseline cognitively. The staff stated the resident had complaints of pain in her knees prior to the fall and would not consistently wear her knee brace. Staff G stated that since returning from the hospital the resident was changed to the use of the EZ Way Lift due to decreased strength and safety. The staff stated all staff were to use a gait belt with all residents when completing transfers. Staff G stated the gait belt was required to be on the staff at all times when working. The staff stated the facility provided gait belts for staff to use while at work, and the cottages had extra gait belts if needed. On 9/20/24 at 2:34 PM Staff H, CNA, stated she assisted Resident #1 to the bathroom. The staff could not recall whether a gait belt was utilized walking to the bathroom. Staff H stated she did not use a gait belt following toileting and when starting to walk back to the resident's bedroom. The staff stated Resident #1 lost her balance, and she was not prepared for that and could not stop the fall. Staff H stated the resident had her FWW with her. Staff H stated she had turned her attention to obtain the resident's glasses from the counter when the resident lost her balance and fell. Staff H stated she was aware of the facility policy requiring the use of gait belt when transferring residents, but at the time was not thinking the steps through as clearly as she should have. The staff did recall receiving the email regarding the resident's assistance needs for transfers and ambulation. On 9/20/24 at 4:36 PM Staff E, CNA, stated staff should always use a gait belt when transferring a resident, and they had recent re-training on the use of gait belts and transfers. On 9/21/24 at 8:25 AM Staff F, CNA, stated staff should always use a gait belt when transferring residents and that she had recent training on transfers and gait belts. On 9/20/24 at 9:45 AM the Administrator stated the facility policy required staff to utilize gait belts for all transfers. The Administrator stated the facility had implemented competency checks during nurse manager rounds, and did a re-training on gait belt use following the fall. The facility provided document, Glen Haven Village Safe Lifting/Transfers, revised 2/21, revealed all non-mechanical transfers require gait belt usage. The document further revealed that staff should wear a gait belt on their person at all times to ensure they were readily available.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, camera footage review and facility policy review the facility failed to assure residents were free from significant medication errors for 1 of 7 resident reviewed (Resident #24). The facility reported a census of 65 residents. Findings Include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #24 documented diagnoses of high blood pressure, Diabetes Mellitus (DM) and hemiplegia. The MDS showed a Brief Interview for Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. The Care Plan for Resident #24 dated 12/1/23 showed the following: - I have the potential for hypoglycemia and hyperglycemia episodes secondary to the diagnosis of DM. - I have the potential for complications related to antiplatelet therapy. - I may have difficulty verbally expressing my needs due to my diagnosis of vascular dementia and recent stroke which affected my vocal cords. The June 2024 Medication Reconciliation Form showed the following medications were administered by Staff D on 6/9/2024 for the 7 PM medication pass: Ferrous Sulfate 325 milligrams (mg) for iron deficiency Metformin 500 mg for diabetes Metoprolol 25 mg for rheumatoid arthritis The MDS assessment dated [DATE] for Resident #13 documented diagnoses of high blood pressure, Parkinson's Disease, seizure disorder and depression. The MDS showed a BIMS score of 10 which indicated a moderately severe cognitive impairment. The Care Plan for Resident #13 dated 6/13/24 showed the following: - I am at risk for complications related to antiplatelet therapy. - I am at risk for adverse consequences related to receiving psychotropic medications for the treatment of depression and bipolar disorder. - My team will administer my anti-seizure medication The June 2024 Medication Reconciliation Form showed the following medications were administered on 6/9/2024 for the 7 PM medication pass: Aspirin 81 mg to prevent blood clotting Cephalexin 250 mg for infection Divalproex DR 500 mg for convulsions/seizures Lamotrigine 100 mg for convulsions/seizures Latanoprost 0.005% eye drops for dry eyes Primidone 50 mg for convulsions/seizures Risperidone 1 mg for bipolar depression Trazadone 100 mg for depression and to treat thought processes and behavioral disorders in people with perceptual disorders. Vitamin D3 25 mcg In an interview on 7/9/24 at 12:32 PM, Staff B, Licensed Practical Nurse (LPN), Care Coordinator stated, she received a phone call overnight from Staff C. She said, I'm not sure but I think the nurse gave the wrong meds to the wrong resident. Staff C explained, Resident #13, reported the nurse came into her room. Resident #13 observed Staff D, Registered Nurse (RN) open her roommate's medication cabinet door (Resident #24), then left the room. Resident #13 stated, the nurse didn't give her the medications. After the call Staff B then called Staff D and asked the nurse, who's medications she gave in room three? Staff D replied, she just got done giving room [ROOM NUMBER] meds. Staff B stated, Staff D was unsure who exactly she gave meds to, but said that she matched residents with pictures, and matched the medications to the MAR. Staff B stated, she told her to monitor the resident just in case she gave wrong meds. Staff B reported despite sending another nurse over to the cottage, they were unable to determine if a medication error occurred. Staff B stated, she came in the next morning for a cottage meeting, they noticed a change in condition in Resident #24, so they called the primary care provider (PCP). The PCP ordered a Risperdal and Depakote level and they were drawn. The test results showed Resident #24 had both medications in her system. Resident #24 didn't have orders for Risperdal and Depakote but her roommate did. We knew then the medication error occurred. Staff C reported the resident was a little more tired than usual. In an interview on 7/9/24 at 3:28 PM, Staff C, Certified Nursing Assistant (CNA) reported Resident #13 and #24 shared a room. Staff C observed Staff D, Registered Nurse (RN) give medications to Resident #24 in the day room. Later as Staff C assisted the roommate, Resident #13, to bed she asked if the resident received medications yet. Resident #13 replied, no. Resident #13 stated she observed the nurse in her medication cabinet and removed the medications from the card containers then left the room. When Staff C told Resident #13 that it was odd the nurse gave her roommate medications and not her. Resident #13 replied, she never saw her go into Resident #24's cabinet. I'm 100% sure. Staff C called Staff B, Licensed Practical Nurse (LPN), Care Coordinator to report Resident #24 may have incorrectly received Resident #13's medications. After the call Staff C found Resident #24 in the day room with her head resting down by her knees and vomit from her knees to the floor. Resident #24 reported her head hurt. Staff C and Staff D then assisted Resident #24 to her room. While in the room Staff C observed Staff D access Resident #24's medication cupboard. Staff C heard Staff D remove medications from each container. Staff C stated, she clearly remembered Staff D attempted to hide the medications with her pointer finger and pinky finger using her left hand. She could not see any pills but the way Staff D held her hands made her think she was hiding them. After that Staff D immediately put her hands down into her pants pockets. Staff C stated, Staff D helped put Resident #24 to bed and left the room. When asked about the Resident's #24 symptoms, Staff C replied, the resident was not throwing up prior to administration that she observed. After that the resident threw up a total of three times after she got meds. The resident also said that her head hurt. In an interview on 7/9/24 at 4:17 PM, the PCP stated, in terms of life threatening, Resident #24 getting Resident #13's medications and psych meds wasn't an imminent danger type of situation but it did throw her for loop for 3 days. The PCP stated he would characterize it as serious but not life threatening. In an interview on 7/10/24 at 12:03 PM, Staff B, LPN, Care Coordinator, reported the day following the medication error Resident #24 requested to stay in bed for meals. Staff B reported, Resident #24 didn't want to get up when staff attempted to get her up for meals. Staff B reported, per documentation, the resident failed to consume meals on 6/9/24, staff assisted the resident to take sips of water. The Progress Note on 6/10/24 at 6:34 AM for Resident #24 showed the following: Called to check on and assess a resident who was reported to have vomited a moderate amount of brown mucus like emesis. Resident observed sitting at the dining table noted with generalized weakness, was awake, lethargic but responsive to tactile stimuli. Resident assisted back to bed and was agitated and combative during transfer and assessment. The Risperidone Lab test collected on 6/10/24 for Resident #24 showed a blood level of 10.9 nanograms/milliliter (ng/ml). Review of the June 2024 MAR for Resident #24 showed Risperidone not ordered. The Depakote lab test collected on 6/10/24 for Resident #24 showed a blood level of 22.1 ng/ml. Review of the June 2024 MAR for Resident #24 showed Depakote not ordered. The Point of Care History for Resident #24 showed the following for the day after the medication error on 6/10/24: How did the resident transfer? Activity did not occur. How did the resident move off the unit? Activity did not occur. The timeline of camera footage for the evening of 6/9/2024 the following was noted: At 6:36 PM Staff D, RN took Resident #24's blood pressure At 6:49 PM Staff D took medication cup into Resident #24's room without the computer. After a few moments the nurse returned to her cart with medications. Staff D placed some of the pills from her hand into a pill crusher sleeve and crushed them, she then opened a capsule pill and emptied the contents into the medication cup along with the crushed pills. At 6:52 PM Staff D walked back toward room [ROOM NUMBER], when she returned she added pudding to the crushed pills in a med cup. At 6:53 PM Staff D approached Resident #24 in the lounge where she sat and administered the medication. By 7:25 PM Resident #24 started to slouch over in her wheelchair in the lounge. At 7:39 Staff C, CNA walked into the lounge and asked Resident #24 what is going on. As Staff C stepped closer to Resident #24 she noticed the vomit. At 7:45 PM Staff D walked out of the hallway where the room is at, the closing of the medication cabinet is audible. Staff D stated, need to give her medications. As Staff D entered the hallway carrying medications, Staff D asked Staff C for assistance with Resident #24. Staff D stated, I can usually get her by herself but she won't sit up. At this time Staff D returned to the room twice, the second time she returned with a drinking cup and what appears to be another med cup. The Medication Administration Policy and Procedure last revised October 2023 identified the following: 1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. 2. Medications are administered in accordance with written orders of the attending physician or physician extender. 3. If a dose seems excessive considering the resident ' s age and condition, or a medication order seems to be unrelated to the resident ' s current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification. This interaction with the pharmacy and /or prescriber and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. 4. Medications are administered at the time they are prepared. Medications are not pre-poured. 5. Medications are administered without unnecessary interruptions. 6. The person who prepares the dose for administration is the person who administers the dose. 7. Residents are identified before medication is administered. Methods of identification include: a. Checking photograph attached to medical record b. Asking resident to say his/her name c. If necessary, verifying resident identification with other facility personnel 8. Hands are washed before and after administration of topical, ophthalmic, otic, parenteral, enteral, rectal, and vaginal medications. 9. At least 4 (four) ounces of water or other acceptable liquid are given with oral medications unless fluid restrictions apply. 10. Medications are administered within one hour before or one hour after scheduled time, except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by prescriber, routine medications are administered according to the established medication administration schedule for the facility. 11. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 12. Medications supplied for one resident are never administered to another resident. 14. For resident ' s not in their rooms or otherwise unavailable to receive medication on the pass, the nurse will not leave medications in the room unattended ever. The nurse will return at a later time to administer medications. 15. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. 16. Identify medication related monitoring and documentation necessary for: Adverse Consequences/Events related to medication use Efficacy Side-Effects In an interview on 7/11/24 at 9:10 AM, the Administrator reported the facility terminated Staff D, RN for not following proper medication administration procedures and because she was not honest about the medication error. The Administrator reported there were many steps in the medication administration process Staff D failed to follow that placed residents at risk.