Health inspection·November 14, 2024

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medication was administered according to the facility ' s policies and procedures (P&P) for one of three sample resident (Resident 1) when Keppra (medication used to treat and prevent seizures—an abnormal electrical activity in the brain that temporarily affects consciousness, muscle control, and behavior) was not administration to Resident 1. This failure potentially has caused Resident 1, who is clinically compromised, being transferred to Hospital for Seizure evaluation on May 3, 2024. Findings: During the review of Resident 1 ' s admission record (a document that gives a summary of resident's information), the document indicated Resident 1 was admitted to the facility on [DATE], with a diagnosis that included Epilepsy (a brain condition where a person experience recurring seizures), and Hemiplegia (a condition that causes paralysis or weakness on one side of the body). During a review of Resident 1 record titled Change in Condition Evaluation, dated May 3, 2024, indicated Resident 1 had a tonic clonic seizure (a type of seizure with sudden stiffening followed by rapid shaking movements) activity lasting 3 minutes, Resident 1 was unresponsiveness, 911 called. Resident was transferred to Hospital. During a concurrent telephone interview and record review, on November 15, 2024, at 10:28 AM, with the Minimum Data Set Coordinator (MDS Coordinator 1), Resident 1 ' s physician orders and Medication Administration Record (MAR) May 2024 was reviewed. Levetiracetam (Keppra) Oral Tablet 750 mg to be given one tablet by mouth two times a day for seizures. The MDS Coordinator 1 acknowledged that the Medication Administration Record (MAR) showed Keppra was not given on May 2, 2024, at 9:00 AM. MDS Coordinator 1 stated on May 2, 2024, Keppra was not given and the nurse cited number 10, which stands for Other, as the reason for not administering it, but she was unable to locate the explanation of Other on the record. She stated that when a nurse uses 10 (other) as an excuse for not administering medicine, the nurse should explain what other implies in the chart. During telephone interview on November 15, 2024, at 11:04 AM, with License Vocational Nurse (LVN 1), LVN 1 stated she was Resident 1 medication nurse on May 2, 2024. She further explains that Keppra was not giving in the morning because the medication was not available pending shipment. LVN 1 Acknowledged that medication should be ordered before it ran out. She added per policy medication should be ordered within 7 days before the last dose. Page 1 of 2 055650 055650 11/14/2024 Highland Care Center of Redlands 700 E Highland Ave Redlands, CA 92374

F 0755 Level of Harm - Minimal harm or potential for actual harm During a review of facility Policy and Procedure titled, Medication Administration, indicated, .3. Staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. 4. Medications are administered in accordance with prescriber orders, including any required time frame . Residents Affected - Few 055650 Page 2 of 2