Health inspection·September 9, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on review of facility self-reported incidents, review of a medication incident investigation, review of staff statements, interviews with staff, and review of facility policy, the facility failed to report allegations of abuse and neglect. This had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of a statement dated 05/21/25 by Licensed Practical Nurse (LPN) #160 revealed she had worked a 12-hour day shift then gave report to the 12-hour night shift nurse LPN #174. LPN #160 revealed she had not left until around 8:00 P.M. LPN #160 stated as she was gathering her things, LPN #174 started putting cups out and putting Tylenol PM and melatonin in everyone's medication cups, then started putting resident medications in those same cups. LPN #160 noted during training LPN #174 would watch movies and sleep on her shift. LPN #160 revealed she called and reported it to the Assistant Director of Nursing (ADON) #196 this same night, wrote a statement and placed it under ADON #196's door. Further review of the investigation revealed there was no documentation the allegations reported on 05/21/25 were investigated.Review of a statement dated 06/04/25 written by Registered Nurse (RN) #212 revealed on 06/04/25 around 7:20 P.M. she stopped in the 100 halls where LPN #174 was standing. RN #212 noticed at least four pill cups with Tylenol PM in them (blue pills with P525 on them). RN #212 stated to LPN #174, Wow you have that many people on Tylenol PM? and LPN #174 replied Yeah, I have a few and turned to give someone their medications. When LPN #174 returned to the cart, RN #212 stated she proceeded to take a picture of the pill cups on her cart. RN #212 stated she had seen LPN #174 prep her medications when she worked but had never got close enough to see what they were until tonight. RN #212 stated she immediately left and notified the Assistant Director of Nursing (ADON) #196 and sent her the pictures.Review of a statement dated 06/05/25 by LPN #174 and emailed to the Former Interim Director of Nursing (FIDON) #800 revealed she was off five days in a row and when she returned she had no clue what the new orders were. LPN #174 stated she always put Tylenol, Melatonin and Tylenol PM's in cups just in case there is a new order. LPN #174 also stated she pre-poured water cups before passing meds, so she was ready, it is available and easier. LPN #174 stated she was doing her medication pass last night at the nurses' station and RN #212 asked Is that Tylenol PM? Do you have that many orders for them? LPN #174 acknowledged what they were and kept on doing the medication pass. LPN #174 stated do I have time before med pass to check all the residents new orders to see if there are new orders for it, so I could not answer her second question. LPN #174 stated RN #212 walked away then came back with her phone out and took a picture of the medication cart and walked away. LPN #174 stated with that being said, lastly, no Tylenol PM were given and the pills went back into the bottle at the end of my medication pass. Review of a statement dated 06/06/25 by ADON #196 revealed on 05/21/25 she had received a call from LPN #160 who had worked on unit one that day. LPN #160 reported LPN #174 started Page 1 of 15 366067 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pre-pouring the residents' nighttime medications and putting Tylenol PM in all the cups. ADON #196 noted no residents on unit one had an order for Tylenol PM. ADON #196 stated she called the Former Director of Nursing (FDON) #566 to report what LPN #160 had reported. ADON #196 revealed FDON #566 told her she had not believed LPN #160 and said, even if it were true, without proof there was nothing we could do. ADON #196 stated when she came in the next day, she took the bottle of Tylenol PM out of the cart since no one had an order for it. ADON #196 noted by the next week there was a new bottle in the cart and opened, the DON at the time was notified. Review of a statement dated 06/09/25 by FIDON #800 noted speaking with Physician #190 on 06/06/26 regarding concerns the facility was investigating a nurse for giving Tylenol PM to residents without an order. Physician #190 had no medical recommendations for necessary attention to this situation.Review of the facility self-reported incidents (SRI) revealed the incidents alleged on 05/21/25 and 06/04/25 had not been reported to the state agency. Interview on 09/03/25 at 8:52 A.M., the Administrator revealed the facility had a report of a nurse giving medications on 06/04/25 without a physician order but could not prove it and the nurse denied giving the medications without an order. The Administrator revealed the nurse was terminated for pre-pouring her medications.Interview on 09/04/25 at 8:50 A.M., ADON #196 revealed RN #212 thought LPN #174 was giving residents Tylenol PM without an order. ADON #196 revealed she reported the incident on 06/04/25 to FIDON #800 who took over the investigation. ADON #196 denied prior knowledge of allegations of LPN #174 administering medications without an order. ADON #196 was given LPN #160's statement dated 05/21/25 to review. ADON #196 initially stated LPN #160 had not written the statement on 05/21/25. ADON #196 was then provided a copy of her own statement dated 06/06/25 revealing her knowledge of the allegation dating back to 05/21/25. ADON #196 stated she had forgotten. ADON #196 stated she reported the allegations from 05/21/25 to the FDON #566 on 05/21/25. ADON #196 stated there was no evidence the residents received the Tylenol PM. ADON #196 revealed she had removed the bottle from the unit one cart and a week later it was back in the cart. ADON #196 revealed none of the residents admitted to receiving the Tylenol PM.Interview on 09/04/25 at 11:10 A.M., FIDON #800 revealed she had worked in the facility for about four weeks from about the beginning of June 2025. FIDON #800 revealed ADON #196 notified her a nurse had reported LPN #174 was pre-pouring her medications and giving residents Tylenol PM and melatonin. FIDON #800 revealed she reported the incident to the Administrator on 06/04/25. FIDON stated LPN #174 was suspended then terminated for pre-pouring her medications. FIDON #800 stated LPN #174 denied administering medications without an order and staff had only witnessed the pre-pouring of the medications but not the actual giving of the medications. FIDON #800 revealed she talked to a couple of the residents on unit one but not all the residents regarding the allegation and could not prove anything. FIDON #800 could not recall any documentation of staff interviews, resident interviews, or completion of resident assessments and monitoring for potential adverse medication reactions. Further interview on 09/04/25 at 11:49 A.M., the Administrator revealed she had not been made aware of the allegations made on 05/21/25 and FDON #566 should have reported to her the allegations and completed an investigation. The Administrator verified the allegations from 05/21/25 and 06/04/25 were not reported to the state agency. Further interview on 09/09/25 at 1:22 P.M., the Administrator verified there was no documentation of staff and resident interviews, resident monitoring, and resident assessments related to the 05/21/25 and 06/04/25 allegations. On 09/09/25 at 1:55 P.M., the Administrator revealed ADON #196 knew about the allegations on 05/21/25 and also should have reported the allegations to her. Review of the undated facility policy Psychotropic Drug and Unnecessary Drug Use, revealed the use of chemical restraints was not consistent with the facility guidelines or standard of practice. A chemical restraint was viewed as an 366067 Page 2 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some approach done by staff for their own convenience or to discipline the resident. Review of the undated facility policy Abuse Prohibition, revealed residents would not be subjected to abuse, neglect, exploitation, mistreatment, or misappropriation of property by anyone. A thorough investigation of all alleged violations would be conducted. Any alleged allegation was to be communicated immediately to the Administrator or designee. Residents would be assessed by the Director of Nursing or designee. The attending physician would be notified, along with family or responsible party. Residents would be interviewed if cognitively able to communicate. All alleged violation concerning abuse, neglect, misappropriation of property, and injuries of unknown origin are reported immediately to the Administrator/Designee. Allegations involving abuse or result in serious bodily injury would be reported to the state agency within two hours after the alleged incident was discovered. Reporting of allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegation would be reported to the state agency within five working days of the incident.This deficiency represents non-compliance investigated under Complaint Number 1331531. 366067 Page 3 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a medication incident investigation, review of staff statements, interviews with staff and residents, and review of facility policy, the facility failed to investigate allegations of abuse and neglect alleged on 05/21/25 and failed to thoroughly investigate an allegation of abuse alleged on 06/04/25. This had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of the medical record for Resident #56 revealed an admission date of 07/09/20. Diagnoses included type two diabetes mellitus, bipolar disorder, paranoid schizophrenia, anxiety, hypertension, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #56's physician orders from 05/21/25 through 06/04/25 revealed the resident had no orders for Tylenol PM (pain reliever/sleep aid). Review of a physician order dated 06/13/25 revealed the resident was ordered Tylenol PM extra strength 500 milligram (mg)/25 mg, one tablet by mouth as needed for insomnia at bedtime.Review of the medical record for Resident #55 revealed an admission date of 02/21/21. Diagnoses included schizoaffective disorder bipolar type, paranoid personality disorder, and depressive disorder. Review of the MDS quarterly assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #55's physician orders from 05/21/25 through 06/04/25 revealed the resident had no orders for Tylenol PM. Review of a physician order dated 06/25/25 revealed an order for Tylenol PM extra strength 500 mg/25 mg, one tablet by mouth every 24 hours as needed for insomnia. Review of a statement dated 05/21/25 by Licensed Practical Nurse (LPN) #160 revealed working a 12-hour day shift then gave report to the 12-hour night shift nurse LPN #174. LPN #160 revealed she had not left until around 8:00 P.M. LPN #160 stated as she was gathering her things, LPN #174 started putting cups out and putting Tylenol PM and melatonin in everyone's medication cups, then started putting resident medications in those same cups. LPN #160 noted during training LPN #174 would watch movies and sleep on her shift. LPN #160 revealed she called and reported it to the Assistant Director of Nursing (ADON) #196 this same night, wrote a statement and placed it under ADON #196's door. Further review of the investigation revealed there was no documentation the allegations reported on 05/21/25 were investigated. Review of the staffing assignment forms from 05/21/25 through 06/04/25 revealed LPN #174 worked on unit one on 05/21/25, 05/22/25, 05/26/25, 05/27/25, 05/28/25, 06/03/25, and 06/04/25.Review of a statement dated 06/04/25 written by Registered Nurse (RN) #212 revealed on 06/04/25 around 7:20 P.M. she stopped in the 100 halls where LPN #174 was standing. RN #212 noticed at least four pill cups with Tylenol PM in them (blue pills with P525 on them). RN #212 stated to LPN #174, Wow you have that many people on Tylenol PM? and LPN #174 replied Yeah, I have a few and turned to give someone their medications. When LPN #174 returned to the cart, RN #212 stated she proceeded to take a picture of the pill cups on her cart. RN #212 stated she had seen LPN #174 prep her medications when she worked but had never got close enough to see what they were until tonight. RN #212 stated she immediately left and notified the Assistant Director of Nursing (ADON) #196 and sent her the pictures. Review of Resident #56's statement dated 06/05/25 taken by Former Interim Director of Nursing (FIDON) #800 revealed the resident was asked if she had been receiving Tylenol PM last night or anytime. Resident #56 stated she had not wished to answer and had not wanted to get anyone in trouble. Resident #56 stated she would like the nurse practitioner to be asked for an order for Tylenol PM because she needed it to help her sleep. FIDON #800 noted the resident had an order for Tylenol 325 milligrams and order for melatonin 10 mg at bedtime. Review of a Residents Affected - Some 366067 Page 4 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some statement dated 06/05/25 by LPN #174 and emailed to FIDON #800 revealed she was off five days in a row and when she returned she had no clue what the new orders were. LPN #174 stated she always put Tylenol, Melatonin and Tylenol PM's in cups just in case there is a new order. LPN #174 also stated she pre-poured water cups before passing meds, so she was ready, it is available and easier. LPN #174 stated she was doing her medication pass last night at the nurses' station and RN #212 asked Is that Tylenol PM? Do you have that many orders for them? LPN #174 acknowledged what they were and kept on doing the medication pass. LPN #174 stated do I have time before med pass to check all the residents new orders to see if there are new orders for it, so I could not answer her second question. LPN #174 stated RN #212 walked away then came back with her phone out and took a picture of the medication cart and walked away. LPN #174 stated with that being said, lastly no Tylenol PM was given and the pills went back into the bottle at the end of my medication pass. Review of a statement dated 06/06/25 by ADON #196 revealed on 05/21/25 she had received a call from LPN #160 who had worked on unit one that day. LPN #160 reported LPN #174 started pre-pouring the residents' nighttime medications and putting Tylenol PM in all of the cups. ADON #196 noted no residents on unit one had an order for Tylenol PM. ADON #196 stated she called the FDON #566 to report what LPN #160 had reported. ADON #196 revealed FDON #566 told her she had not believed LPN #160 and said, even if it were true, without proof there was nothing we could do. ADON #196 stated when she came in the next day, she took the bottle of Tylenol PM out of the cart since no one had an order for it. ADON #196 noted by the next week there was a new bottle in the cart and opened, the DON at the time was notified. Review of a statement dated 06/09/25 by FIDON #800 noted speaking with Physician #190 on 06/06/26 regarding concerns the facility was investigating a nurse for giving Tylenol PM to residents without an order. Physician #190 had no medical recommendations for necessary attention to this situation. Further review of the facility investigation revealed no documentation the pharmacy was contacted. Also, there were no interviews completed with the residents residing on unit one and there was no documentation of resident assessments or monitoring. Interview on 09/03/25 at 8:52 A.M., the Administrator revealed the facility had a report of a nurse giving medications on 06/04/25 without a physician order but could not prove it and the nurse denied giving the medications without an order. The Administrator revealed the nurse was terminated for pre-pouring her medications. Further interview on 09/04/25 at 11:49 A.M., the Administrator revealed she had not been made aware of the allegations made on 05/21/25 and FDON #566 should have reported to her the allegations and completed an investigation. The Administrator verified the allegations from 05/21/25 and 06/04/25 were not reported to the state agency. Further interview on 09/09/25 at 1:22 P.M., the Administrator verified there was no documentation of staff and resident interviews, resident monitoring, and resident assessments related to the 05/21/25 and 06/04/25 allegations. On 09/09/25 at 1:55 P.M., the Administrator revealed ADON #196 knew about the allegations on 05/21/25 and also should have reported the allegations to her. Interview on 09/03/25 at 8:18 A.M., LPN #136 revealed LPN #174 was giving medications without an order but no longer worked here. LPN #136 revealed FDON #566 and ADON #196 were notified. LPN #136 revealed she had not witnessed LPN #174 giving medications to the residents without an order. LPN #136 revealed she heard the residents on unit one were receiving two Tylenol PM with no physician order. LPN #136 revealed she usually worked on unit one and was never told to assess or monitor the residents for adverse effects of possibly being given medications without an order. Interview on 09/04/25 at 7:43 A.M., LPN #163 revealed LPN #174 would pre-pour resident medications including blue Tylenol PM medications which the resident had no physician orders for. LPN #174 revealed she had reported the incident to FDON #566 and ADON #196. Interview on 09/04/25 at 8:50 A.M., ADON #196 revealed RN #212 thought LPN #174 was 366067 Page 5 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some giving residents Tylenol PM without an order. ADON #196 revealed she reported the incident on 06/04/25 to FIDON #800 who took over the investigation. ADON #196 denied prior knowledge of allegations of LPN #174 administering medications without an order. ADON #196 was given LPN #160's statement dated 05/21/25 to review. ADON #196 initially stated LPN #160 had not written the statement on 05/21/25. ADON #196 was then provided a copy of her own statement dated 06/06/25 revealing her knowledge of the allegation dating back to 05/21/25. ADON #196 stated she had forgotten. ADON #196 stated she reported the allegations from 05/21/25 to the FDON #566 on 05/21/25. ADON #196 stated there was no evidence the residents received the Tylenol PM. ADON #196 revealed she had removed the bottle from the unit one cart and a week later it was back in the cart. ADON #196 revealed none of the residents admitted to receiving the Tylenol PM. Interview on 09/04/25 at 1:09 P.M., Resident #19 was unaware if she had received Tylenol PM.Interview on 09/04/25 at 1:17 P.M., Resident #11 was not aware if he had received Tylenol PM. Interview on 09/04/25 at 12:58 P.M., Resident #56 revealed LPN #174 was giving her two Tylenol PM without a physician order. Resident #56 revealed she now had an order for the Tylenol PM but she could only have one now even though two worked better. Interview on 09/04/25 at 11:10 A.M., FIDON #800 revealed she had worked in the facility for about four weeks from about the beginning of June 2025. FIDON #800 revealed ADON #196 notified her a nurse had reported LPN #174 was pre-pouring her medications and giving residents Tylenol PM and melatonin. FIDON #800 revealed she reported the incident to the Administrator on 06/04/25. FIDON stated LPN #174 was suspended then terminated for pre-pouring her medications. FIDON #800 stated LPN #174 denied administering medications without an order and staff had only witnessed the pre-pouring of the medications but not the actual giving of the medications. FIDON #800 revealed she talked to a couple of the residents on unit one but not all the residents regarding the allegation and could not prove anything. FIDON #800 could not recall any documentation of staff interviews, resident interviews, and the completion of resident assessments and monitoring for potential adverse medication reactions.Interview on 09/04/25 at 3:32 P.M., Resident #44 revealed taking medications the nurses gave her. Resident #44 revealed she was not aware if she had received any medications not ordered by the physician. Interview on 09/08/25 at 10:00 A.M., Physician #190 revealed he had been notified a nurse may have been giving medications without an order. Physician #190 revealed he would have expected nursing staff to keep an eye on the residents and monitor them closely for a change in condition and check vital signs. Physician #190 stated these things happen and this was a mild medication error, and he had not anticipated any problems for the residents. Interview on 09/08/25 at 1:10 P.M., LPN #501 revealed she had removed a Tylenol PM bottle from the unit one medication cart as no residents had physician orders for the medication. LPN #501 revealed the medication ended up back in the cart. LPN #501 revealed ADON #196 was aware. LPN #501 revealed she was not sure which residents had received the medication, if any. Interview on 09/08/25 at 4:39 P.M., Resident #67 revealed he was unaware if he had received medications without a physician order. Interview on 09/09/25 at 7:22 A.M., RN #212 revealed on 06/04/25 she saw LPN #174 put Tylenol PM and melatonin in all the residents medication cups with their regular medication and take the cart down the hall and start passing medication. RN #212 revealed no resident had an order for Tylenol PM. RN #212 revealed she wrote a statement and took pictures of the cart and sent them to ADON #196. RN #212 revealed she had not watched LPN #174 hand the medications to the residents. Interview on 09/09/25 at 1:26 P.M., the current Director of Nursing (DON) revealed a thorough investigation was not completed for the allegation on 06/04/25 of medications being administered without an order. The DON stated she would have notified residents and resident representatives. The DON revealed the physician should be notified immediately, not two days later. The DON revealed she would have 366067 Page 6 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pulled the staffing schedules to check where LPN #174 had worked. The DON also revealed she would have checked allergies for the residents on unit one and notified the pharmacy to check for medication interactions. The DON revealed staff, and the potentially affected residents should have been interviewed, monitored, and assessed for adverse reactions and there should have been documentation of the notifications, interviews, monitoring, and assessments. Interview on 09/09/25 at 1:36 P.M., LPN #160 revealed on 05/21/25 she gave report to LPN #174. LPN #160 revealed she witnessed LPN #174 set up all the resident medications for unit one and put Tylenol PM in the cups, then taking the cart down the hall and start passing the medications. LPN #160 revealed during her training she noticed LPN #174 would also watch movies on her phone and sleep at the nurses station. LPN #160 stated she wrote a statement on 05/21/25 and reported the incident to ADON #196. LPN #160 revealed other nurses had previously reported LPN #174 doing the same thing to FDON #566 but nothing was ever done about it. Interview on 09/09/25 at 3:12 P.M., Resident #55 revealed a nurse used to give her two Tylenol PM. Resident #55 revealed the two Tylenol PM were helpful, but she only received one Tylenol PM now. Resident #55 was unable to remember the name of the nurse. Review of LPN #174's personnel record revealed a hire date of 04/09/23 and a termination date of 06/04/25 for performance and violation of company policy. Review of the undated facility policy Psychotropic Drug and Unnecessary Drug Use, revealed the use of chemical restraints was not consistent with the facility guidelines or standard of practice. A chemical restraint was viewed as an approach done by staff for their own convenience or to discipline the resident. Review of the undated facility policy Abuse Prohibition, revealed residents would not be subjected to abuse, neglect, exploitation, mistreatment, or misappropriation of property by anyone. A thorough investigation of all alleged violations would be conducted. Any alleged allegation was to be communicated immediately to the Administrator or designee. Residents would be assessed by the Director of Nursing or designee. The attending physician would be notified, along with family or responsible party. Residents would be interviewed if cognitively able to communicate. All alleged violation concerning abuse, neglect, misappropriation of property, and injuries of unknown origin are reported immediately to the Administrator/Designee. Allegations involving abuse or result in serious bodily injury would be reported to the state agency within two hours after the alleged incident was discovered. Reporting of allegations not involving abuse or serious bodily injuries must not exceed 24 hours. The results of a thorough investigation of the allegation would be reported to the state agency within five working days of the incident.This deficiency represents non-compliance investigated under Complaint Number 1331531. 366067 Page 7 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of a fall investigation, review of staffing assignment records, interviews with staff and residents, and policy review, the facility failed to ensure a resident was reevaluated for transfer assistance after a change in condition and ensure a safe resident transfer. Additionally, the facility failed to ensure falls were immediately reported, immediate post-fall assessments were completed and ensure the completion of a thorough fall investigation. This affected one (#7) of three residents reviewed for falls and had the potential to affect 56 residents residing on unit one and unit two. The facility census was 87. Review of the medical record for Resident #7 revealed an admission date of 02/21/23. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, acquired absence of right leg below the knee, type two diabetes mellitus, and a diabetic foot ulcer. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition. The resident was at risk for falls.Review of a physician order dated 12/08/23 revealed the resident required the assistance of one staff and pivot transfer with walker. The order was discontinued on 07/01/25. Review of a physical therapy Discharge summary dated [DATE] revealed the resident required supervision or touching assistance with transfers. The resident was discharged from therapy using a walker.Review of a fall risk assessment dated [DATE] revealed the resident was at risk for falls. Review of the plan of care initiated on 02/23/23 revealed the resident had impaired mobility and relied on staff for assistance with activities of daily living (ADL ' s). The resident had a right leg prosthesis. Interventions included extensive assistance by staff with transferring, use of walker for transfers with pivot and the care plan was noted as resolved on 01/22/25. On 01/22/25 the resident was noted as requiring weight bearing assistance with sit to stand, lying to sitting, and transfers. On 02/19/25 an intervention was added for mechanical lift transfers until new prosthetic was received. Review of a nurse ' s note dated 01/27/25 at 1:26 P.M. revealed Resident #7 had a three centimeter (cm) in length by 2.5 cm in width blister noted to the right anterior stump. The resident stated his prosthetic rubs and caused the blister, red patches were also noted. The nurse practitioner was notified with new wound care orders received. The blister was noted as healed on 02/10/25.Review of a nurse ' s note dated 01/28/25 at 8:54 A.M. revealed the resident was scheduled to have his prosthetic leg evaluated by a provider on 02/13/25. There was no documentation in the medical record of the resident attending the appointment. Review of a nurse ' s note dated 01/30/25 at 9:39 A.M. revealed Resident #7 was not wearing prosthetic to right stump related to pain/ill fitting. Appointment scheduled for adjustment. Review of a physician order dated 01/30/25 revealed to not wear prosthetic to right stump until after follow up with orthopedics. Further review of the medical record revealed no documentation the resident ' s transfer status was reevaluated after the inability to wear the right lower extremity prosthesis. Review of the weight documentation revealed the resident weighed 236 pounds on 01/20/25 and 238 pounds on 02/19/25. Review of an incident report dated 02/19/25 at 1:25 P.M. revealed a nursing assistant informed the nurse Resident #7 had a fall two days ago. The resident revealed he had fallen and landed on his buttocks. The nursing assistants helped him up with the help of his roommate to hold the chair then put him back in bed and left the room. Review of statement dated 02/19/25 by Certified Nursing Assistant (CNA) #601 revealed on 02/17/25 CNA #602 went to transfer Resident #7, and he fell. CNA #601 revealed she was only in the room to watch. CNA #601 revealed CNA #602 fell on top of Resident #7. CNA #602 told CNA #601 not to report the fall because Resident #7 was fine and was not hurt. Review of statement dated 02/19/25 by CNA #602 revealed on 02/17/25 Resident #7 said he needed to have a bowel movement. CNA #602 366067 Page 8 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated normally we transfer to the toilet in shower room but a resident was using the toilet, so we laid Resident #7 down and after he was done, CNA #601 and myself transferred him. Resident #7 was on part of the chair and slid. We asked the resident ' s roommate Resident #67 to push the chair under him while we lifted him into the chair. CNA #602 stated Resident #7 never touched the floor that he was aware of. CNA #602 revealed we were told Resident #7 was either a two assist or a mechanical lift. Review of a statement dated 02/19/25 by CNA #99 revealed CNA #601 notified her at home that Resident #7 fell when CNA #602 attempted to get the resident out of bed with a stand/pivot transfer. CNA #602 and CNA #601 had not used the mechanical lift. CNA #601 stated CNA #602 landed on top of the resident. CNA #601 stated CNA #602 told her not to say a word about the incident. CNA #601 stated she reported the incident to LPN #174. CNA #99 revealed she returned to work today 02/19/25 and Resident #7 ' s roommate was asking questions. CNA #99 revealed she reported the incident to the nurse who notified Former Director of Nursing (FDON) #566. Review of an undated statement by Licensed Practical Nurse (LPN) #136 revealed CNA #99 reported CNA #601 told her CNA #602 dropped a resident and to not tell anyone. CNA #99 stated Resident #7 ' s roommate told her about what happened. LPN #136 reported the incident to FDON #566. Review of a statement by LPN #174 dated 02/19/25 revealed no one had reported any falls to her in the past three days. Review of a nurses note dated 02/19/25 at 1:45 P.M. revealed a nursing assistant reported she was told a fall had occurred for Resident #7. Resident #7 verified the fall stating it happened two days ago. The nurse reported the incident to FDON #566. The resident was assessed with no injuries noted. The nurse practitioner was notified of the fall on 02/19/25.Review of a physician order dated 02/19/25 revealed for the resident to transfer with a mechanical lift as needed. An order dated 02/20/25 revealed to transfer with mechanical lift every shift.Review of a nurses note dated 02/20/25 at 8:42 A.M. revealed the resident denied pain and his range of motion was within normal limits. The resident voiced no complaints regarding the fall on 02/17/25. Review of a nurses note dated 02/20/25 at 9:06 A.M. revealed therapy was consulted and gave the okay to make the resident a mechanical lift transfer at this time until his appointment to evaluate his prosthesis. Nursing department made aware of the change and care plan would be updated to change in transfer. Review of a therapy fall screen dated 02/20/25 revealed the resident had transfer concerns and ambulation concerns, used a forward wheeling walker, felt unsteady standing or walking, had had a change in mobility and activities of daily living. The therapy note revealed the resident would be evaluated for therapy after his orthopedic appointment. The resident reported a fall when transferred by two nursing assistants. The resident was unable to wear right lower extremity prosthesis due to improper fit. Staff to use mechanical lift for transfers.Interview on 09/08/25 at 11:12 A.M., Resident #7 revealed CNA #602 and CNA #601 tried to lift him out of bed without using the mechanical lift. Resident #7 stated CNA #602 was facing him and put his arms around his back and had not had a good grip on him. Resident #7 stated he slipped and fell to the floor. Resident #7 stated CNA #602 was not using a gait belt. Resident #7 stated CNA #602 had not fallen on him but some of CNA #602 ' s weight was on the resident. Resident #7 reported he was not injured. Resident #7 revealed staff usually used the mechanical lift to transfer him since 12/2024 but CNA #602 had not wanted to wait and get the lift. Resident #7 revealed staff were using the lift because he could no longer wear his prosthetic leg due to wounds on his leg and his leg getting bigger. Resident #7 revealed CNA #602 asked him not to report the fall because he would get in trouble and CNA #601 agreed with CNA #602 to not report the fall. Resident #7 revealed he was not using his walker. Interview on 09/08/25 at 1:36 P.M., Rehabilitation Director (RD) #150 revealed Resident #7 had blisters and could not wear his prosthetic leg. RD #150 revealed the resident had a fall and after the fall she had recommended 366067 Page 9 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some staff to use the mechanical lift to transfer the resident. TD #150 revealed she was not notified when Resident #7 ' s blister occurred or his inability to wear his prosthesis, or she would have reevaluated the resident. Interview on 09/08/25 at 2:34 P.M., CNA #152 revealed Resident #7 was a one assist when he could wear his prosthetic leg and was a two assist when he could not wear it which had been for a while. Interview on 09/08/25 at 3:01 P.M., the Administrator revealed Resident #7 had missed his appointment to have his prosthesis evaluated on 02/13/25 because he was sick. Interview on 09/08/25 at 4:39 P.M. with Resident #67 (Resident #7 ' s former roommate) revealed he could not recall Resident #7 falling or assisting staff with a wheelchair for Resident #7. Resident #67 stated if Resident #7 had a fall then he must not have been in the room. Interview on 09/09/25 at 11:07 A.M., the Director of Nursing (DON) revealed for a fall investigation, statements should be completed, the resident assessed, notifications made to the physician and family/responsible party and ensure interventions were in place and new interventions were appropriate. The DON revealed falls were discussed in morning meeting and a follow up interdisciplinary note was documented. Further interview with the DON revealed a thorough fall investigation had not been completed for Resident #7. The DON revealed since staff had not reported the fall then follow up resident interviews and assessments should have been completed on all potentially affected residents to ensure other falls had not been reported. The DON verified there was no documentation if staff had used a gait belt or the resident ' s walker or what interventions were in place at the time of the fall. The DON revealed the resident should have been reevaluated for transfers when he could no longer use his prosthetic leg. Review of the staffing schedules from 02/03/25 through 02/17/25 revealed CNA #601 and CNA #602 were assigned to residents on unit one and unit two. Interview on 09/09/25 at 11:10 A.M., Corporate MDS Registered Nurse (CMDSRN) #622 verified there was no reevaluation of the resident ' s ability to transfer when he could no longer wear his prosthesis. Interview on 09/09/25 at approximately 11:00 A.M. with Assistant Director of Nursing (ADON) #196 revealed Resident #7 was not using his prosthetic leg prior to his fall. ADON #196 revealed she thought staff were using the mechanical lift to transfer the resident. ADON #196 was not sure why the resident was not using his walker. ADON #196 revealed if the resident was not using his prosthesis then we would have discussed that in morning meeting. ADON #196 revealed RD #150 was present at morning meetings and would have been aware the resident may have needed reevaluated for transfers. Interview on 09/09/25 at 12:18 P.M., CNA #602 revealed CNA #601 assisted him to transfer Resident #7 from the bed to the wheelchair. CNA #602 stated they were on each side of the resident to lift him to the wheelchair. CNA #602 revealed Resident #7 started sliding out of the wheelchair and we asked the resident ' s roommate to push the wheelchair back under the resident. CNA #602 revealed they were not using a gait belt and should have used a gait belt during the transfer. CNA #602 also verified they were not using the resident ' s walker and he could not recall the resident ever using a walker. CNA #602 stated the resident was not using his prosthetic leg and it was not safe to transfer the resident with one person. CNA #602 revealed he had not reported the incident because he had not considered it a fall because the resident ' s bottom touched his foot and not the floor. CNA #602 revealed he should have reported the incident to the nurse. CNA #602 denied falling on the resident. CNA #602 denied the resident required a mechanical lift transfer. Interview on 09/09/25 at 4:21 P.M., Quality Assurance Registered Nurse (QARN) #180 revealed staff should have used a gait belt when transferring Resident #7 and should have been using his walker per his physician orders and plan of care. Review of the personnel records for CNA #601 and CNA #602 revealed both were terminated for not reporting Resident #7 ' s fall on 02/17/25. Review of the undated facility policy Fall Management revealed the facility would identify each resident who was at risk for falls and 366067 Page 10 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some would develop a plan of care and implement interventions to manage falls. The licensed nurse would perform a fall risk assessment immediately if the resident was deemed to be at risk. The care plan would be updated routinely and with significant change in the resident ' s condition. Review of the facility procedural guidelines Safe Patient Handling and Mobility, revealed to consult with physical therapy for best transfer methods for resident and physical therapy would conduct a functional assessment. Staff were to use a gait belt, sling, or lapboard (as needed), lateral transfer device, mechanical lift or stand assist lift device for transfers. If the resident was partially or not at all able to assist and was greater than 200 pounds then use a ceiling lift with supine sling, a lateral transfer device or air-assisted device with three caregivers. This deficiency represents non-compliance investigated under Complaint Number 2570390, Complaint Number 1331531, and Complaint Number 1331530. 366067 Page 11 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 medical record review, review of a facility medication incident investigation, review of staff statements, staff and resident interviews, and policy review, the facility failed to ensure medications were administered per physician orders. Additionally, the facility failed to assess and monitor for potential medication interactions and adverse medication effects. This affected two (#55, #56) of three residents reviewed for medications and had the potential to affect 38 residents (#2, #5, #8, #10, #11, #13, #14, #16, #18, #19, #22, #26, #30, #37, #38, #40, #44, #46, #49, #52, #53, #55, #56, #88, #57, #59, #61, #63, #66, #67, #70, #72, #77, #78, #79, #80, #82, and #85) residing on unit one. The facility census was 87. Review of the medical record for Resident #56 revealed an admission date of 07/09/20. Diagnoses included type two diabetes mellitus, bipolar disorder, paranoid schizophrenia, anxiety, hypertension, and chronic obstructive pulmonary disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #56's physician orders from 05/21/25 through 06/04/25 revealed the resident had no orders for Tylenol PM (pain reliever/sleep aid). Review of a physician order dated 06/13/25 revealed the resident was ordered Tylenol PM extra strength 500 mg/25 mg, one tablet by mouth as needed for insomnia at bedtime.Review of the medical record for Resident #55 revealed an admission date of 02/21/21. Diagnoses included schizoaffective disorder bipolar type, paranoid personality disorder, and depressive disorder. Review of the MDS quarterly assessment dated [DATE] revealed the resident had intact cognition.Review of Resident #55's physician orders from 05/21/25 through 06/04/25 revealed the resident had no orders for Tylenol PM. Review of a physician order dated 06/25/25 revealed an order for Tylenol PM extra strength 500 mg/25 mg, one tablet by mouth every 24 hours as needed for insomnia. Review of a statement dated 05/21/25 by Licensed Practical Nurse (LPN) #160 revealed working a 12-hour day shift then gave report to the 12-hour night shift nurse LPN #174. LPN #160 revealed she had not left until around 8:00 P.M. LPN #160 stated as she was gathering her things, LPN #174 started putting cups out and putting Tylenol PM and Melatonin in everyone's medication cups, then started putting resident medications in those same cups. LPN #160 revealed she called and reported it to the Assistant Director of Nursing (ADON) #196 this same night, wrote a statement and placed it under ADON #196's door. Review of the staffing assignment forms from 05/21/25 through 06/04/25 revealed LPN #174 worked on unit one on 05/21/25, 05/22/25, 05/26/25, 05/27/25, 05/28/25, 06/03/25, and 06/04/25.Review of a statement dated 06/04/25 written by Registered Nurse (RN) #212 revealed on 06/04/25 around 7:20 P.M. she stopped in the 100 halls where LPN #174 was standing. RN #212 noticed at least four pill cups with Tylenol PM in them (blue pills with P525 on them). RN #212 stated to LPN #174, Wow you have that many people on Tylenol PM? and LPN #174 replied Yeah, I have a few and turned to give someone their medications. When LPN #174 returned to the cart, RN #212 stated she proceeded to take a picture of the pill cups on her cart. RN #212 stated she had seen LPN #174 prep her medications when she worked but had never got close enough to see what they were until tonight. RN #212 stated she immediately left and notified the Assistant Director of Nursing (ADON) #196 and sent her the pictures. Review of Resident #56's statement dated 06/05/25 taken by Former Interim Director of Nursing (FIDON) #800 revealed the resident was asked if she had been receiving Tylenol PM last night or anytime. Resident #56 stated she had not wished to answer and had not wanted to get anyone in trouble. Resident #56 stated she would like the nurse practitioner to be asked for an order for Tylenol PM because she needed it to help her sleep. FIDON #800 noted the resident had an order for Tylenol 325 milligrams and order for Melatonin 10 mg at bedtime. Review of a statement dated 06/05/25 by LPN #174 and 366067 Page 12 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some emailed to FIDON #800 revealed she was off five days in a row and when she returned she had no clue what the new orders were. LPN #174 stated she always put Tylenol, Melatonin and Tylenol PM's in cups just in case there is a new order. LPN #174 also stated she pre-poured water cups before passing meds, so she was ready, it is available and easier. LPN #174 stated she was doing her medication pass last night at the nurses' station and RN #212 asked Is that Tylenol PM? Do you have that many orders for them? LPN #174 acknowledged what they were and kept on doing the medication pass. LPN #174 stated do I have time before med pass to check all the residents new orders to see if there are new orders for it, so I could not answer her second question. LPN #174 stated RN #212 walked away then came back with her phone out and took a picture of the medication cart and walked away. LPN #174 stated with that being said, lastly no Tylenol PM was given and the pills went back into the bottle at the end of my medication pass. Review of a statement dated 06/06/25 by ADON #196 revealed on 05/21/25 she had received a call from LPN #160 who had worked on unit one that day. LPN #160 reported LPN #174 started pre-pouring the residents' nighttime medications and putting Tylenol PM in all of the cups. ADON #196 noted no residents on unit one had an order for Tylenol PM. ADON #196 stated she called the FDON #566 to report what LPN #160 had reported. ADON #196 revealed FDON #566 told her she had not believed LPN #160 and said, even if it were true, without proof there was nothing we could do. ADON #196 stated when she came in the next day, she took the bottle of Tylenol PM out of the cart since no one had an order for it. ADON #196 noted by the next week there was a new bottle in the cart and opened, the DON at the time was notified. Review of a statement dated 06/09/25 by FIDON #800 noted speaking with Physician #190 on 06/06/26 regarding concerns the facility was investigating a nurse for giving Tylenol PM to residents without an order. Physician #190 had no medical recommendations for necessary attention to this situation. Further review of the facility investigation revealed no documentation the pharmacy was contacted. Also, there were no interviews completed with the residents residing on unit one and there was no documentation of resident assessments or monitoring. Interview on 09/03/25 at 8:52 A.M., the Administrator revealed the facility had a report of a nurse giving medications on 06/04/25 without a physician order but could not prove it and the nurse denied giving the medications without an order. The Administrator revealed the nurse was terminated for pre-pouring her medications. Further interview on 09/04/25 at 11:49 A.M., the Administrator revealed she had not been made aware of the allegations made on 05/21/25 and FDON #566 should have reported to her the allegations and completed an investigation. The Administrator verified the allegations from 05/21/25 and 06/04/25 were not reported to the state agency. Further interview on 09/09/25 at 1:22 P.M., the Administrator verified there was no documentation of staff and resident interviews, resident monitoring, and resident assessments related to the 05/21/25 and 06/04/25 allegations. On 09/09/25 at 1:55 P.M., the Administrator revealed ADON #196 knew about the allegations on 05/21/25 and also should have reported the allegations to her. Interview on 09/03/25 at 8:18 A.M., LPN #136 revealed LPN #174 was giving medications without an order but no longer worked here. LPN #136 revealed FDON #566 and ADON #196 were notified. LPN #136 revealed she had not witnessed LPN #174 giving medications to the residents without an order. LPN #136 revealed she heard the residents on unit one were receiving two Tylenol PM with no physician order. LPN #136 revealed she usually worked on unit one and was never told to assess or monitor the residents for adverse effects of possibly being given medications without an order. Interview on 09/04/25 at 7:43 A.M., LPN #163 revealed LPN #174 would pre-pour resident medications including blue Tylenol PM medications which the resident had no physician orders for. LPN #174 revealed she had reported the incident to FDON #566 and ADON #196. Interview on 09/04/25 at 8:50 A.M., ADON #196 revealed RN #212 thought LPN #174 was giving residents Tylenol PM without an 366067 Page 13 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some order. ADON #196 revealed she reported the incident on 06/04/25 to FIDON #800 who took over the investigation. ADON #196 denied prior knowledge of allegations of LPN #174 administering medications without an order. ADON #196 was given LPN #160's statement dated 05/21/25 to review. ADON #196 initially stated LPN #160 had not written the statement on 05/21/25. ADON #196 was then provided a copy of her own statement dated 06/06/25 revealing her knowledge of the allegation dating back to 05/21/25. ADON #196 stated she had forgotten. ADON #196 stated she reported the allegations from 05/21/25 to the FDON #566 on 05/21/25. ADON #196 stated there was no evidence the residents received the Tylenol PM. ADON #196 revealed she had removed the bottle from the unit one cart and a week later it was back in the cart. ADON #196 revealed none of the residents admitted to receiving the Tylenol PM. Interview on 09/04/25 at 1:09 P.M., Resident #19 was unaware if she had received Tylenol PM.Interview on 09/04/25 at 1:17 P.M., Resident #11 was not aware if he had received Tylenol PM. Interview on 09/04/25 at 12:58 P.M., Resident #56 revealed LPN #174 was giving her two Tylenol PM without a physician order. Resident #56 revealed she now had an order for the Tylenol PM, but she could only have one now even though two worked better. Interview on 09/04/25 at 11:10 A.M., FIDON #800 revealed she had worked in the facility for about four weeks from about the beginning of June 2025. FIDON #800 revealed ADON #196 notified her a nurse had reported LPN #174 was pre-pouring her medications and giving residents Tylenol PM and Melatonin. FIDON #800 revealed she reported the incident to the Administrator on 06/04/25. FIDON stated LPN #174 was suspended then terminated for pre-pouring her medications. FIDON #800 stated LPN #174 denied administering medications without an order and staff had only witnessed the pre-pouring of the medications but not the actual giving of the medications. FIDON #800 revealed she talked to a couple of the residents on unit one but not all the residents regarding the allegation and could not prove anything. FIDON #800 could not recall any documentation of staff interviews, resident interviews, and completion of resident assessments and monitoring for potential adverse medication reactions.Interview on 09/04/25 at 3:32 P.M., Resident #44 revealed taking medications the nurses gave her. Resident #44 revealed she was not aware if she had received any medications not ordered by the physician. Interview on 09/08/25 at 10:00 A.M., Physician #190 revealed he had been notified a nurse may have been giving medications without an order. Physician #190 revealed he would have expected nursing staff to keep an eye on the residents and monitor them closely for a change in condition and check vital signs. Physician #190 stated these things happen and this was a mild medication error, and he had not anticipated any problems for the residents. Interview on 09/08/25 at 1:10 P.M., LPN #501 revealed she had removed a Tylenol PM bottle from the unit one medication cart as no residents had physician orders for the medication. LPN #501 revealed the medication ended up back in the cart. LPN #501 revealed ADON #196 was aware. LPN #501 revealed she was not sure which residents had received the medication, if any. Interview on 09/08/25 at 4:39 P.M., Resident #67 revealed he was unaware if he had received medications without a physician order. Interview on 09/09/25 at 7:22 A.M., RN #212 revealed on 06/04/25 she saw LPN #174 put Tylenol PM and Melatonin in all the residents medication cups with their regular medication and take the cart down the hall and start passing medication. RN #212 revealed no resident had an order for Tylenol PM. RN #212 revealed she wrote a statement and took pictures of the cart and sent them to ADON #196. RN #212 revealed she had not watched LPN #174 hand the medications to the residents. Interview on 09/09/25 at 1:26 P.M., the current Director of Nursing (DON) revealed a thorough investigation was not completed for the allegation on 06/04/25 of medications being administered without an order. The DON stated she would have notified residents and resident representatives. The DON revealed the physician should be notified immediately, not two days later. The DON revealed she would have pulled the staffing schedules to check 366067 Page 14 of 15 366067 09/09/2025 Vista Care Center of Milan 185 S Main St Milan, OH 44846

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some where LPN #174 had worked. The DON also revealed she would have checked allergies for the residents on unit one and notified the pharmacy to check for medication interactions. The DON revealed staff, and the potentially affected residents should have been interviewed, monitored, and assessed for adverse reactions and there should have been documentation of the notifications, interviews, monitoring, and assessments. Interview on 09/09/25 at 1:36 P.M., LPN #160 revealed on 05/21/25 she gave report to LPN #174. LPN #160 revealed she witnessed LPN #174 set up all the resident medications for unit one and put Tylenol PM in the cups, then taking the cart down the hall and start passing the medications. LPN #160 revealed during her training she noticed LPN #174 would also watch movies on her phone and sleep at the nurses station. LPN #160 stated she wrote a statement on 05/21/25 and reported the incident to ADON #196. LPN #160 revealed other nurses had previously reported LPN #174 doing the same thing to FDON #566 but nothing was ever done about it. Interview on 09/09/25 at 3:12 P.M., Resident #55 revealed a nurse used to give her two Tylenol PM. Resident #55 revealed the two Tylenol PM were helpful, but she only received one Tylenol PM now. Resident #55 was unable to remember the name of the nurse. Review of LPN #174's personnel record revealed a hire date of 04/09/23 and a termination date of 06/04/25 for performance and violation of company policy. Review of the facility policy Medication Administration, dated 12/2012 revealed prior to administration, nurses would review and confirm medication orders for each individual resident on the Medication Administration Record. Personnel authorized to administer medication do so only after they have familiarized themselves with the medication. Medications are administered in accordance with written orders of the prescriber. Medications were to be administered at the time they were prepared. Note allergies or contraindication the resident may have prior to medication administration. The individual who administers the medication dose records the administration on the residents MAR immediately following the medication being given. Once removed from the package/container, unused medication doses shall be disposed of according to the nursing care center policy. Observe resident for medication actions/reactions and record in the nurses notes as appropriate.This deficiency represents non-compliance investigated under Complaint Number 1331531. 366067 Page 15 of 15