Based on observation, interview, and record review the facility failed to ensure call lights were within reach for residents (Resident's #16, #27 and #28) who were dependent on the facility staff for their care. This affected three residents (Resident's #16, #27 and #28) out of three residents reviewed for accommodation of needs. Findings include: 1. Review of Resident #27's medical record revealed an admission date of 01/24/17 and diagnoses included bilateral osteoarthritis of hip, major depressive disorder, recurrent, severe with psychotic symptoms, and vascular dementia. Review of Resident #27's Minimum Data Set (MDS) 3.0 assessment, dated 05/19/21 revealed resident was cognitively intact, was one person physical assist and required extensive assistance with bed mobility and transfers. Review of Resident #27's care plan, dated 07/20/21, revealed the resident was at risk for injury related to falls due to unsteady gait, balance, incontinence, impaired cognition with poor safety awareness and impulsivity, risk of medication side effects, diagnosis of arthritis and vascular dementia. A goal was included to minimize potential risk factors related to falls. An intervention dated 12/3/19 stated to encourage use of call light when assistance was needed. Observation on 7/26/21 at 11:54 A.M. of Resident #27 laying in bed, the call light was on the floor behind her bedside table, out of reach, and was not able to be used by the resident. Interview on 07/26/21 at 11:55 A.M. of Resident #27 revealed the call light was not in reach if she needed to use it, it did not work properly and in order for it to work the button must be continually held down. Resident #27 stated the call light had not been working properly for quite a while. Interview on 7/26/21 at 12:02 P.M. of Unit Manager/Licensed Practical Nurse (UM/LPN) #519 confirmed Resident #27's call light was laying on floor out of the residents reach and did not work when pressed unless the button was continually held down. Interview on 07/26/21 at 12:05 P.M. of Resident #27 indicated the call light had been been broken for quite awhile, she told nurses and State Tested Nursing Assistants the light was not working but could not remember their names. Resident #27 stated she told STNA $582 the call light was not working. Attempts on 07/29/21 at 10:08 A.M. and 07/30/21 at 10:10 A.M. to contact STNA #582 were unsuccessful. Interview on 7/26/21 at 12:06 P.M. of Maintenance Director (MD) #532 confirmed Resident #27's call light was broken and he would get it fixed. Interview on 07/26/21 at 12:26 P.M. of MD #532 stated he checked the call light system monthly to be sure the lights were working properly. MD #532 stated he needed to replace Resident #27's call light because there was something wrong with the wires. 2. Review of Resident #28's medical record revealed an admission date of 02/12/21 and diagnoses included dementia with behavioral disturbances, anxiety, and depression. Review of Resident #28's MDS 3.0 assessment, dated 05/20/21, revealed resident had severe cognitive impairment, was a one person physical assist and required extensive assistance with bed mobility and transfer. Review of Resident #28's care plan, dated 05/20/21, revealed the resident was at risk for falls, had poor safety awareness related to dementia with behavioral disturbances, muscle weakness, received psychotropic medication, and required some assistance with transfers. Interventions included ensure call light was within reach. Observation on 07/26/21 at 11:09 A.M. of Resident #28 sleeping in bed, revealed the call light was located behind the head of bed and not able to be used by the resident. Observation on 07/26/21 at 4:37 P.M. and 4:52 P.M. revealed Resident #28 was laying on her right side in bed, was sleeping, and the call light was out of reach behind the head of the bed. Observation on 7/27/21 at 4:25 P.M. revealed Resident #28 was laying in her bed and the call light was behind the head of the bed and out of resident reach. Observation and interview on 7/28/21 at 10:41 A.M. of Resident #28 with LPN #556 revealed Resident #28 sitting on the side of the bed, the call light was behind the head of the bed and out of the resident's reach. LPN #556 stated Resident #28 could not use the call light or reach the call light where it was located and moved the call light so it was within Resident #28's reach. 3. Review of Resident #16's medical record revealed an admission date of 06/14/18 and diagnoses included dysphagia, vascular dementia, and cerebrovascular disease. Review of the MDS 3.0 assessment, dated 04/27/21, revealed Resident #16 was unable to complete the Brief Interview for Mental Status (BIMS) due to she was rarely if never understood. Further review revealed Resident #16 was a two person physical assist and required extensive assistance for bed mobility, and was a two person physical assist and total dependence for transfers. Review of Resident #16's medical record revealed she was placed in hospice care on 01/15/21. Observation on 07/26/21 at 4:02 P.M. revealed Resident #16 was laying in bed on her left side, and the call light was on the floor at the foot of her bed and unable to be reached by the resident. Observation on 7/27/21 at 2:38 P.M. and 4:23 P.M. revealed Resident #16 was laying in bed on left side, and the call light cord and button were looped around area where it met the wall. The call light was far from resident reach. Interview on 07/27/21 at 4:30 P.M. of STNA #580 confirmed the call light was looped around area where it met the wall and far from Resident #16's reach. STNA #580 moved the call light so Resident #16 was able to reach it if needed. Interview on 07/30/21 at 3:45 P.M. of Administrator #606 revealed the facility did not have a call light policy.

Based on interview and record review, the facility failed to ensure physical abuse allegations were accurately and timely reported within the required two hour time frame to the State Agency. This affected one resident (Resident #57) out of one resident reviewed for reporting of physical abuse. Findings include: Review of Resident #57's medical record revealed an admission date of 02/14/20 and diagnoses included dementia with behavioral disturbances, wandering, and depression. Review of Resident #57's Minimum Data Set (MDS) 3.0 assessment, dated 07/06/21, revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment revealed Resident #57 was a one person physical assist and needed extensive assistance with locomotion and walking in corridor. The assessment revealed Resident #57 was not steady but able to stabilize without staff assistance for walking. Review of Resident #57's care plan, dated 06/04/20, revealed the resident experienced alteration in behavior as evidenced by wandering the halls on the unit, wandering in and out of other resident rooms, and takes items belonging to others at times. Interventions, dated 06/04/20, included distraction and redirection as needed and an intervention, dated 07/03/20, included staff to monitor location on the unit to provide cueing to discourage wandering into other resident rooms, and assist with movement to common area or assist with finding her own room. Review of Resident #57's progress notes on 04/09/21 at 6:39 P.M. revealed Licensed Practical Nurse (LPN) #564 heard yelling coming from the hallway. When she arrived at the location of yelling, State Tested Nursing Assistant (STNA) #599 was re-directing Resident #57 out of Resident #48's room. STNA #599 stated Resident #48 slapped Resident #57 on the left side of the face. The left side of Resident #57's face was observed to be red with no swelling and the skin was intact. A small red spot on Resident #57's back was also noted. Review of Resident #57's shower sheet dated 04/12/21 revealed resident had a red area on her left cheek and right upper back. Review of the Self Reported Incident (SRI) #204779 created 04/12/21 at 10:13 A.M. by Administrator #602 (three days after the incident) included in the Summary of Incident Section, on 04/09/21 at approximately 6:20 P.M., Resident #48 made contact with Resident #57, and the residents were separated. Resident #57 was assessed and no new skin abnormalities were noted including no swelling, redness, bruises, scratches or abrasions were noted. The SRI inaccurately reported Resident #57's injuries. Review of the facility Employee Education and Training Document, dated 04/12/21 revealed LPN #564 was educated on the Abuse Policy due to LPN #564 failed to notify the Abuse Coordinator within a timely manner of an alleged abuse incident. Review of STNA #599's witness statement revealed on 04/09/21 at 6:20 P.M. she was walking in the hallway and heard a resident yell don't hit her and by the time she arrived to the scene of yelling she observed Resident #48 smack Resident #57 in the face and yelled get out of my room. STNA #599 separated the residents, re-directed Resident #57 away from Resident #48 and reported the incident to LPN #564. Interview on 07/29/21 at 3:20 P.M. with Administrator #606 and the Director of Nursing revealed although Resident #57's progress note and shower sheet identified the resident sustained injuries as a result of the incident that occurred on 04/09/21, the facility could not confirm of deny that the SRI submitted on 04/12/21 accurately reflected the resident's injuries. Interview on 07/30/21 at 8:45 A.M. of LPN #564 confirmed Resident #57 was slapped by Resident #48 and the left side of her face had a red mark. LPN #564 stated the residents were immediately separated, Resident #57 was re-directed away from Resident #48's room and a stop sign barrier was placed on Resident #48's door. Attempt to contact STNA #599 on 07/29/21 at 2:00 P.M. was unsuccessful due to STNA #599 no longer working in the facility. 2. Review of Resident #57's progress notes on 05/31/21 at 9:45 A.M. included staff heard a resident yell get out of my room. A loud thud was heard and Resident #57 was observed on the floor, lying on her back in front of Resident #40's room. Resident #57 stated he hit me. Resident #40 and #57 were separated. Resident #57 was assessed and her pupils were pinpoint and fixed, she was unable to express pain, swelling was noted to the back of her head, and her upper back and left cheek were red. A pillow was placed under Resident #57's head and she was kept still. Certified Nurse Practitioner (CNP) #600 was notified, local Fire and Police Department staff arrived to the facility and Resident #57 was transported to the local hospital by Emergency Medical Services (EMS). Review of Resident #57's Incident/Accident Body Assessment, dated 05/31/21, revealed redness to left cheek, right upper back redness, and swelling to the back of her head. Review of the facility SRI #206879 created on 05/31/21 at 11:23 A.M. by Administrator #602 included in the Summary of Incident Section on 05/31/21 at 9:45 A.M. there was a resident to resident altercation between Resident #40 and Resident #57. No contact was witnessed by facility staff. Resident #57 was assessed and no new noted skin abnormalities were observed including no swelling, redness, bruises, scratches, or abrasions. Resident #40 was placed on one to one supervision. Staff working on the unit had no relevant findings. The SRI inaccurately reported Resident #57's injuries. Interview on 07/28/21 at 1:22 P.M. of STNA #573 revealed on 05/31/21 she was working on the secured unit and she heard a loud noise like something hitting something really hard, heard a scream, and Resident #40 yelled get out of my room. STNA #573 observed Resident #57 sitting on the floor and Resident #40 standing in the doorway. STNA #573 asked Resident #40 if he pushed Resident #57 and he stated he did not want anyone in his room. STNA #573 stated she observed a bump on the back of Resident #57's head and redness under her neck between her shoulder blades. STNA #573 stated she reported the incident to LPN #541 and staff from the local Police and Fire Departments arrived to the facility and Resident #57 was taken to the hospital by EMS. Interview on 07/28/21 at 2:54 P.M. of Certified Occupational Therapy Assistant (COTA) #603 revealed she was working with another resident on the secured nursing unit on 05/31/21 when she heard yelling and the words get out of my room, and saw Resident #57 fly backward and lose her balance. COTA #603 stated Resident #57 fell on her butt, and her head went back and hit the door frame. At the same time she saw Resident #40 standing in the doorway to his room. LPN #541 arrived on scene and assessed Resident #57. Interview on 07/29/21 at 3:20 P.M. with Administrator #606 and the Director of Nursing revealed although Resident #57's Incident/Accident Body Assessment identified the resident sustained injuries as a result of the incident that occurred on 05/31/21, the facility could not confirm of deny that the SRI submitted on 05/31/21 accurately reflected the resident's injuries. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation of Resident Property, dated 11/21/16 included it is the facility's policy to investigate all alleged violations involving Abuse, Neglect, Exploitation, Mistreatment of a resident, or Misappropriation of Resident Property, including Injuries of Unknown Source. Additionally, the facility should immediately report all such allegations to the Administrator and to the Ohio Department of Health (ODH). In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than two hours after the allegation is made to the Administrator or designee of the facility and to other officials, including the State Survey Agency, in accordance with State law.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure resident significant weight change was addressed by the physician. This affected one resident (#32) of one resident reviewed for nutrition. Findings include: Review of the medical record for Resident #32 revealed an admission date of 08/03/18. Diagnoses included Amyotrophic Lateral Sclerosis (ALS), dementia with Lewy bodies, and diabetes mellitus. Review of the dietary assessment narrative dated 03/09/2021 at 2:30 P.M. revealed the resident continued on Regular diet order and fed self in the dining room with no chewing or swallowing difficulty. The resident's current diet provided 2230 calories and 93 grams protein and the resident's meal intakes were approximately 25-100%. The resident needed cueing from staff due to advanced dementia. The resident's height was 63 inches, weight on 03/04/21 was 135.5 pounds, weight on 11/04/20 was 156 pounds, and weight on 09/04/20 was 157.5 pounds. The resident triggered for significant weight loss of 20.5 pounds which was 13.1% from the weight on 10/12/2020 of 156.5 pounds. The weight loss was probable related to decreased intake and appetite due to COVID 19 diagnosis. Review of the nursing notes dated 03/01/21 through 04/20/21 revealed no evidence the physician addressed Resident #32's weight loss. Review of the physician progress notes dated 04/07/21 revealed the physician did not address Resident #32's weight loss. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had weight loss that was not physician prescribed. Interview on 07/29/21 at 2:48 P.M. with the Administrator and the DON verified the physician progress note dated 04/07/21 did not address Resident #32's significant weight loss on 03/04/21.

Based on observation, interview, and record review, the facility failed to provide the necessary supervision for Resident #57 to prevent injuries and transportation to the local Emergency Department. This affected one resident (Resident #57) out of one resident reviewed for dementia care. Findings include: Review of Resident #57's medical record revealed an admission date of 02/14/20 and diagnoses included dementia with behavioral disturbances, wandering, and depression. Review of Resident #57's Minimum Data Set (MDS) 3.0 assessment dated , 07/06/21 revealed the resident was unable to complete the Brief Interview for Mental Status (BIMS). Further review of the MDS assessment revealed Resident #57 was a one person physical assist and needed extensive assistance with locomotion and walking in corridor. The assessment revealed Resident #57 was not steady but able to stabilize without staff assistance for walking. Review of Resident #57's care plan, dated 06/04/20, revealed the resident experienced alteration in behavior as evidenced by wandering the halls on the unit, wandering in and out of other resident rooms, and taking items belonging to others at times. Interventions ,dated 06/04/20, included distraction and redirection as needed and an intervention, dated 07/03/20, included staff were to monitor location on the unit to provide cueing to discourage wandering into other resident rooms, and assist with movement to common area or assist with finding her own room. 1. Review of Resident #57's progress notes on 04/09/21 at 6:39 P.M. revealed Licensed Practical Nurse (LPN) #564 heard yelling coming from the hallway. When she arrived at the location of yelling, State Tested Nursing Assistant (STNA) ##599 was re-directing Resident #57 out of Resident #48's room. STNA #599 stated Resident #48 slapped Resident #57 on the left side of the face. The left side of Resident #57's face was observed to be red with no swelling and the skin was intact. A small red spot on Resident #57's back was also noted. Interview on 07/30/21 at 8:45 A.M. of LPN #564 confirmed Resident #57 was slapped by Resident #48 and the left side of her face had a red mark. LPN #564 stated the residents were immediately separated, Resident #57 was re-directed away from Resident #48's room and a stop sign barrier was placed on Resident #48's door. Attempt to contact STNA #599 on 07/29/21 at 2:00 P.M. was unsuccessful due to STNA #599 no longer working in the facility. Review of Resident #57's shower sheet dated 04/12/21 revealed resident had a red area on her left cheek and right upper back. Review of STNA #599's witness statement on 04/09/21 at 6:20 P.M. included she was walking in the hallway and heard a resident yell don't hit her and by the time she arrived to the scene of yelling she observed Resident #48 smack Resident #57 in the face and yelled get out of my room. STNA #599 separated the residents, re-directed Resident #57 away from Resident #48 and reported the incident to LPN #564. 2. Review of Resident #57's progress notes written by LPN #541 on 05/31/21 at 9:45 A.M. included staff heard a resident yell get out of my room. A loud thud was heard and Resident #57 was observed on the floor, lying on her back in front of Resident #40's room. Resident #57 stated he hit me. Resident #40 and #57 were separated. Resident #57 was assessed and her pupils were pinpoint and fixed, she was unable to express pain, swelling was noted to the back of her head, her upper back and left cheek were red. A pillow was placed under Resident #57's head and she was kept still. Certified Nurse Practitioner (CNP) #600 was notified, local Fire and Police Department staff arrived to the facility and Resident #57 was transported to the local hospital by Emergency Medical Services (EMS). Review of Resident #57's Emergency Department discharge instructions on 05/31/21 included instructions titled, Head Injury, Adult. The discharge instructions stated to follow up with primary care physician in the next two or three days for further evaluation and management. Please return to the Emergency Department for new or worsening symptoms. Take Tylenol every six hours as needed for pain. Review of Resident #57's Incident/Accident Body assessment dated , 05/31/21 revealed redness to left cheek, right upper back redness, and swelling to the back of her head. Interview on 07/28/21 at 1:22 P.M. of STNA #573 revealed on 05/31/21 she was working on the secured unit and she heard a loud noise like something hitting something really hard, heard a scream, and Resident #40 yelled get out of my room. STNA #573 observed Resident #57 sitting on the floor and Resident #40 standing in the doorway. STNA #573 asked Resident #40 if he pushed Resident #57 and he stated he did not want anyone in his room. STNA #573 stated she observed a bump on the back of Resident #57's head and redness under her neck between her shoulder blades. STNA #573 stated she reported the incident to LPN #541 and staff from the local Police and Fire Departments arrived to the facility and Resident #57 was taken to the hospital by EMS. STNA #573 further stated the STNA's try to keep an eye on the residents, but there was not always enough staff and things happen sometimes. STNA #573 stated two STNA's on the secured unit were not enough to supervise the residents, because the residents required a lot of care and could not be rushed. Interview on 07/28/21 at 2:54 P.M. of Certified Occupational Therapy Assistant (COTA) #603 revealed she was working with another resident on the secured nursing unit on 05/31/21 when she heard yelling and the words get out of my room, and saw Resident #57 fly backward and lose her balance. COTA #603 stated Resident #57 fell on her butt, and her head went back and hit the door frame. At the same time she saw Resident #40 standing in the doorway to his room. LPN #541 arrived on scene and assessed Resident #57. COTA #603 stated she left when LPN #541 arrived and did not stay for the assessment. Review of the daily assignment sheets for 05/31/21 revealed LPN #541 was assigned to the second floor secured unit. LPN #605 split her assignment between the first floor nursing unit and the second floor secured unit. Two STNA's (STNA #520 and #552) were assigned to the secured second floor nursing unit at the time of the altercation between Resident #40 and Resident #57. Observation on 07/26/21 at 1:00 P.M. of Resident #57 in Resident #10s room revealed there were no STNA ' s or nurses present. STNA #580 confirmed Resident #57 often wandered into resident rooms and needed to be re-directed to a different location. Interview on 07/26/21 at 1:02 P.M. with STNA #580 confirmed Resident #57 was in Resident #10 ' s room and there were no STNA ' s or nurses present in the room. Interview on 07/28/21 at 10:03 A.M. of LPN #556 revealed more nurses and STNA's should be assigned to the secured unit. LPN #556 stated it was hard to administer medications, give showers and keep an eye on the residents, especially the wandering residents. Observation on 07/28/21 at 3:00 P.M. of Resident #57 wander into Resident #16 ' s room and began touching the furniture. There was no observation of staff in the room or hall supervising Resident #57. Interview on 07/28/21 at 3:05 P.M. of STNA #607 confirmed Resident #57 was in Resident #16 ' s room and there were no STNA ' s or nurses in the room during that time. STNA #607 stated Resident #57 wandered a lot and was hard to keep track of. Interview on 07/29/21 at 2:20 P.M. of STNA #604 revealed Resident #57 wandered a lot and was hard to keep track of. STNA #604 stated she often wandered into other residents rooms and sometimes the residents were very upset when this happened. STNA #604 stated Resident #27 was really mean to Resident #57 recently when she wandered into her room. STNA #604 stated it would help keep an eye on the residents if there were more STNA's assigned to the secured unit. Interview on 07/29/21 at 2:30 P.M. of LPN #561 revealed Resident #57 wandered a lot and often needed re-directed from entering other resident rooms. LPN #561 stated it would really help to have more STNA's assigned to the secured unit to assist with monitoring the residents, especially the wanderers, to be proactive and prevent problems before they occur. LPN #561 further stated Resident #57 entered Resident #27's room uninvited a few days ago and Resident #27 was very upset and screamed at her to get out. Review of the facility policy titled, Alzheimer's/Dementia Unit Protocol, dated 03/2005 included the Alzheimer's/Dementia Program includes a comprehensive set of standards, policies, and practices designed specifically to establish a unit within the facility that is a safe and therapeutic service provider for residents with Alzheimer's, dementia and related disorders. Ensuring a safe residential environment through implementation of permanent changes to the facility's physical plant as well as day-to-day safety considerations by all facility associates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Centers for Disease Control (CDC) recommendations, observation and interview, the facility failed to ensure proper infection control practices were maintained on the first floor unit. This had the potential to affect 14 residents (#23, #24, #38, #45, #46, #58, #59, #261, #262, #264, #265, #267, #313, #316) that resided on the first floor. Findings include: Review of the medical record for Resident #313 revealed he admitted to the facility on [DATE] and was on isolation precautions due to recent admission. Review of the medical record for Resident #264 revealed he admitted to the facility on [DATE] and was on isolation precautions due to recent admission. Observation on 07/26/21 at 10:30 A.M. revealed an isolation container at the entrance of Resident #264 and #313 room who both resided on the facility first floor unit. Observation revealed there were no gloves, mask or gowns to enter the room to maintain proper infection control practices. Interview on 07/26/21 at 10:30 A.M. with Resident #264 and #313 revealed they were both on isolation precautions due to recent admission to the facility. Observation on 07/26/21 at 12:40 P.M. revealed STNA #579 passing meal trays for the first floorunit. Observation revealed STNA #579 checking multiple isolation containers to locate personal protective equipment (masks and gowns). Interview on 07/26/21 at 12:40 P.M. with Licensed Practical Nurse (LPN) #560 confirmed STNA #579 could not locate any masks or gowns in multiple isolation containers. Observation on 07/26/21 at 12:45 P.M. revealed four isolation containers located on first floor unit. Observation revealed isolation containers were not stocked with mask and gowns. Observation revealed all four containers did not have mask and gowns to enter the isolation rooms. Observation on 07/26/21 at 12:45 P.M. revealed LPN #560 walking down the residents' hall without a face mask on checking isolation containers for a face mask. Observation revealed LPN #560 obtained a face mask from the receptionist desk. Interview on 07/26/21 at 12:45 P.M. with LPN #560 confirmed there were no face masks located in isolation containers and a face mask had to obtained from the receptionist desk. Review of in-service records dated 01/13/21 and 02/18/21 revealed all departments were trained on infection control that included hand washing protocol, personal protective equipment, donning and doffing, and contact and droplet isolation. Review of the CDC, Coronavirus Disease 2019 (Covid-19), Interim Infection Prevention and Control recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Infection Control Guidance, updated 02/23/21, stated Healthcare Personnel (HCP) should wear a face mask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. Review of the facility document titled Infection Prevention and Control Program (IPCP) revised 11/28/17, revealed the facility had a policy in place to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of the document revealed supplies necessary for adherence to proper personal protective equipment use (gloves, gowns, masks) were readily available in resident care areas (i.e., nursing units, therapy rooms). Review of the document revealed the facility did not implement the policy regarding the infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide treatment of a resident's high blood pressure. This affected one of nineteen residents reviewed, Resident #46. Findings Include: Record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses that included dementia, heart disease and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #46 was severely cognitively impaired and required extensive assistance for her activities of daily living. Review of the physicians orders for Resident #46 revealed an order dated 02/21/19 to check blood pressure every six hours and if systolic blood pressure (measure of pressure on the blood vessels when the heart beats) is greater than 160 to administer as needed clonidine (blood pressure medication) and a subsequent order for as needed clonidine 0.1 milligram (mg) every six hours as needed. Review of Resident #46's blood pressure readings noted blood pressures of 173/89 on 02/23/19, two readings of 163/71 on 02/25/19, 171/83 on 02/28/19 and 168/85 on 03/01/19. Review of the medication administration record (MAR) revealed Resident #46 received clonidine 0.1 (mg) on 02/23/19. No other instances of Resident #46 receiving the medication as ordered were noted in the medical record. On 03/12/19 at 4:02 P.M. the Director of Nursing, during interview, verified the lack of treatment of the resident's high blood pressure.